Death of autistic care leaver two weeks after 18th birthday highlights catastrophic failure of corporate parenting

An inquest into the death of an "extremely vulnerable" autistic teenager found a lack of transitional support and information sharing among those responsible for her care contributed to her death.

Nonita Grabovskyte was struck by a train on 28 December 2023, two weeks after turning 18. She had previously told doctors she planned to take her own life when she reached this age, writing in a journal: "I won't be supervised like I am right now..."

Nonita was autistic and had a history of mental ill health, disordered eating, self-harm and hospitalisation. She told professionals she had been sexually abused in early childhood.

The London Borough of Barnet had been her corporate parent since May 2022, after a member of the public stopped her jumping off a bridge. 

Nonita had four periods of hospitalisation before her death. She had asked to live with foster carers, but none were available. She was moved to The Singhing Tree in May 2023, privately-run supported accommodation meant for older children in care, which at the time was unregulated.

The inquest heard the operations director of the home had no social work qualification, no training in autism, and last attended safeguarding training in 2021 or 2022.

Nonita told the owner of the facility that she was "concerned about being seen" near a fenced railway station close to a local park she frequented.

The conversation was noted in a monthly report to the local authority.

In July 2023, Nonita was hospitalised for six days following a serious self-harm incident. Professionals did not discuss this, or her fears about being seen at the nearby station, in subsequent statutory reviews of her welfare.

Representatives of the supported accommodation told the inquest had they known about Nonita's intentions, they would have questioned the suitability of their property, given its location close to train tracks.

The operations director told the inquest he had not been given or read any of Nonita's care plans, despite information sharing this being a legal duty, and he did not know of her intention to take her own life.

Nonita had completed her GCSEs, obtaining good grades, at a specialist school for children with mental health difficulties. 

She had secured a college place to study for a Level 3 Animal Management qualification from early September 2023. But the offer was rescinded once the college received information about the support Nonita would need to complete her studies. 

She was discharged from CAMHS in October 2023, with no plans in place for adult mental health support. Around the same time, her relationship with her art therapist, described as significant, came to an end.

She was referred to adult social care, but no assessment was made prior to her death. It is unclear whether Nonita knew she had been informed of the referral.

An education, health and care plan assessment in November 2023 found Nonita was "feeling stressed, bored and sad."

In December 2023, Nonita's Action for Children independent visitor, Katharine Bryson, raised written safeguarding concerns about her lack of enrolment in education and her general unhappiness.

Nonita wanted the concerns passed on, but they did not reach social services until after her death.

Her final child in care statutory review was conducted on 4 December, followed by her 18th birthday on 13 December. 

She attended a Christmas lunch at the council’s leaving care office on 20 December, which left her feeling “overwhelmed”. Nonita then spent Christmas Day in her supported living accommodation.

On 28 December 2023, Nonita died after being struck by a train in north-west London, on railway tracks close to where she was living.

Paying tribute to Nonita, Katharine Bryson said: ““Nonita was a vibrant, talented young person who loved animals and was seeking a purpose in life. She had recently achieved a good set of GCSEs and had aspirations to work with animals, something she sadly never got to realise. I believe with the right support in place, she could have lived a full life.

“It is shocking to me that so little support was in place to help Nonita cope. It is tragically too late for Nonita but I am also aware that there are hundreds or indeed thousands of young people living in conditions… where they are not part of a family or receiving adequate (if any) care and support. 

“These young people deserve so much more than they are currently receiving.” 

Coroner’s findings

The coroner found that Nonita formed the intention to take her own life, and that the following probably made a more than minimal contribution to her death:

• The absence of co-ordinated transition from secondary school to college as a looked after child.
• The absence of a co-ordinated transition out of CAMHS as a highly vulnerable looked after child, leaving Nonita without any specialist mental health support from 13 December 2023.
• The absence of a co-ordinated transition out of children’s social care, resulting in several key decisions for Nonita’s future being unresolved or unconfirmed by the time of her 18th birthday. 
• The absence of co-ordinated information-sharing between the various agencies involved in Nonita’s care which inhibited effective assessment and management of risk.

Commenting on the findings, Carolyne Willow, Senior Children’s Rights Advisor at Article 39, said: “The inquest process has laid bare a litany of failures in the state’s discharge of its legal and moral obligations towards this highly vulnerable young person.

“If the term ‘corporate parent’ is to have any meaning, then the coroner’s findings as to what may have prevented Nonita’s death should have every local authority across the country checking in on the children in their care who are approaching adulthood.

“It beggars belief that a child with Nonita’s exceptionally high level of vulnerabilities, and known risk of suicide, was placed in unregulated accommodation where she could not legally receive any day-to-day care, and that so many critical aspects of her life remained uncertain as she approached her 18th birthday.”

Deborah Coles, executive director of INQUEST, a charity concerned with state-related deaths, added: “It is vital that when care leavers die while still effectively in the care of the state, there is proper scrutiny to ensure learning and prevent future deaths. 

“The fact it took two NGOs to secure this level of scrutiny reflects a system that too often sees these deaths as inevitable.

“We welcome the coroner’s recognition under Article 2 that the state, as corporate parent, owes a clear and enforceable duty of care to those in its charge. This is a vital acknowledgment – not just of the rights of Nonita, but of the responsibilities that must be upheld by those who were entrusted with her care.”

The coroner will be issuing a Prevention of Future Deaths report to London Borough of Barnet and North London NHS Foundation Trust in relation to the lack of transitional support for Nonita.