Suspected suicide of Charedi teenager prompts calls for better safeguarding

The report was commissioned, BSCB said, because the case raised “potential issues of national importance”.

It stated that the “overarching issue which must be urgently addressed is the risk is that children from the Charedi Jewish community in Bury are not being safeguarded effectively”.

Daniel, who was part of a large family, had asthma and a number of food allergies and, during the last three years of his life, was given various medication for ADHD (attention deficit hyperactivity disorder).

In September 2015 his independent Orthodox school wrote to his parents to say that his behaviour was “challenging at best and often untenable”. Among other things, the school said that he became wild easily, fought with other children, did not respond well to authority and had written phrases such as “kill the teacher” and “hate school” on work assignments.

He relished playing the victim and was also “something of a hypochondriac”, the school said.

When he was suspended the following month, his parents withdrew him permanently from the school. Although the school offered free tutoring, the parents did not take it up.

For a year, he was home-schooled by his mother and then sent to a number of schools abroad.

In April 2017, Daniel was taken to the emergency department of North Manchester Hospital after a friend told the ambulance services he had taken an overdose and begun to shake. Friends reported him saying he had remembered “strange things” and seen frightening images.

Although Daniel told the hospital staff he had taken 100 tablets, he later denied it and while his behaviour was described as “unusual” on his discharge the following day, the cause was noted as “unclear”.

His mother later told BSCB that when Daniel’s elder brother went through the contents of Daniel’s phone at the time, he asked why he hadn’t been on “suicide watch”.

Although the Multi-Agency Safeguarding Hub (MASH) telephoned his parents shortly after the hospital episode, they received no reply as it was Pesach. And although the parents received a letter to tell them there had been a referral to social care, there was no follow up.

“It seems clear that Daniel had become an increasingly troubled young person who may have had largely unmet mental health needs by the time of his death,” BSCB concluded. “His needs went largely unexplored as a result of a missed opportunity when he was admitted to hospital.”

Early in 2018, a local GP referred Daniel to Healthy Young Minds, a service dealing with mental issues in children under 16. But in March, his parents cancelled the appointment saying it was unnecessary.

His mother had become frustrated at the time she felt it would take for him to receive attention and decided to seek help from a psychiatrist within the Charedi community, “although this did not prove successful”.

Five months later, when his mother called police to the house, they found he had “apparently been asphyxiated through an inhalation of helium to the exclusion of oxygen”. There were no injuries on his body and no suicide note.

His mother later told BCSB that he may have been suffering from post-traumatic stress disorder, resulting from being “treated very badly” much earlier at school, although she had only become aware of this after he had left. His behaviour was too extreme for him simply to be thought a “difficult child”.

Days before his death, a fellow pupil at his school had spoken to him about physical abuse they may have suffered there years earlier, the report noted.

Daniel’s mother generally felt that children in her community were “not well supported”.

Although smartphones were banned for example, she said, that didn’t stop children acquiring them and Daniel had secretly obtained one.

As internet access was not allowed, the report said, “the schools did not feel obliged to provide guidance on online safety.”

Many Charedi schools were “behind the times,” she believed, providing inadequate guidance on child abuse, drugs and alcohol.

The report said that in the period immediately before his death, there was an indication Daniel had been smoking cannabis. Schools did not mention child abuse could take place within families, Daniel’s mother said, nor did they share information about grooming — “an issue which she said was not understood in her community”. Lack of safeguarding information was compounded by parental naivety.

The mother also felt children with behavioural problems were characterised as “bad”, leaving the underlying issues unexplored.

In the report’s words, she told BSCB her community was “quite resistant to seek outside help”, preferring to get support inside, “which in her experience, was not always reliable”. Overall, she “felt that her son had been let down by a range of people in the community”.

In its overview, the report said there were “relatively high levels of mental health issues” within the local Charedi community, linked to poverty, unemployment, poor housing and “a tendency for some individuals to engage in obsessively stringent religious behaviours”.

Many families were struggling financially and had been disproportionately hit by the benefit cap.

But the intervention of outside agencies was perceived by the community to be “heavy-handed and intrusive”, leading to a “perpetual cycle of mistrust”.

In addition, the sense of “shame and embarrassment” often associated with mental health diagnoses represented a “significant barrier to seeking help from outside”.

Within the Charedi community, the report said, there was “an idea that experiences of depression may relate to individual sin and failure to live a life in accordance with Jewish law”.

Parents also feared a child’s prospects of marriage could be harmed if a mental health problem became known.

It noted the “prevalence” of ADHD within the Charedi community, with one person suggesting that sometimes a diagnosis of it was sought in order to get medication to “control” large families. BSCB was told a local GP (not associated with Daniel’s medical practice) had been suspended for over-prescribing Ritalin (used in the treatment of ADHD).

When Daniel was admitted to hospital in 2017, the response of several agencies “fell below the expected level”, the report found. There had been a missed opportunity to provide him and his family support.

MASH had “adopted an overly sensitive approach in not pursuing contact with his parents during the Passover holiday or thereafter,” the report said.

“Whilst it is always important to be sensitive to religious beliefs, there were safeguarding concerns about Daniel which needed to be addressed.”

In its recommendations, the report urged dialogue between statutory services and the local Charedi community to “build mutual trust” and “overcome barriers”. It noted that at the time Daniel was withdrawn from school, there was no obligation — as there has been since 2016 — for the school to notify the local authority.

His subsequent attendance of schools abroad may have disrupted his healthcare and “adversely affected his access to mental health services”.

The report also called on the Department for Education to ensure that the exclusion of pupils from Charedi independent schools is examined in inspections.

The approach taken by Daniel’s schools towards exclusion appeared “unduly harsh”, it found.

The language the school had used to describe him “suggested an ethos in which the provision of support to struggling pupils was not prominent, although the school has advised this review that lack of funding limited the support they could offer pupils at risk of exclusion.”

Bury Council said this week that the recommendations of the report, published in summer, have been developed into an action plan. Its progress will be kept under review by the Bury Integrated Safeguarding Partnership.

A spokesman for the Fed, the Jewish social care service for Greater Manchester, said "Religious and cultural beliefs, whatever they are, should never be a barrier to the safeguarding of children or influence the way statutory agencies respond to concerns as they arise."

Bury Safeguarding Children Board, the Fed noted, has accepted all the recommendations of the review in full and will work to ensure that they are implemented.  

"In order to achieve this it will be necessary for all agencies, including these providing education and assistance within the Charedi Jewish community, to work together towards a common aim, which is to ensure that our young people are not only safe but thrive "