AT the outset of the four-day inquest into the death of Lauren Lelonek, her dad Ian told the coroner he hoped that ‘serious lessons’ could be learned from the tragedy.

The 16-year-old from Rudheath tragically took her own life after a prolonged bullying campaign in and out of school, during which she began to suffer from low mood and on occasion self-harmed.

Almost three and a half years after her death, a coroner has found that there were chances for Lauren's school, the police, and healthcare providers to step in.

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Below, we take an in-depth look at what went wrong and how it has been addressed - largely as a result of Lauren's death.

Cheshire Police - missed opportunity to convict bullies

CONVICTIONS of girls who bullied Lauren Lelonek for a year leading up to her death could have been secured before the teenager took her own life, a coroner has said.

Police investigations into assaults, threats and intimidation against Lauren and best friend Libby Boland were criticised during a four-day inquest into Lauren’s death.

Incidents ranging from September 2015 through to February 2016 were reported to the police, after which Lauren continued to tell friends and family how scared she was of the bullies.

Lauren was assaulted in October 2015 outside Northwich Memorial Court, and threatened – as well as being called a ‘grass’ – after reporting it to the police.

She formally withdrew the allegation, citing exam pressures, with the officer at the time placing on record that he had enough evidence to charge and that the incident should support any future case against the perpetrators.

However, this did not happen. In December she was grabbed by the hair and kicked in the head while walking along the road with Libby.

The investigation into this assault was left to go cold on an officer’s desk until March, when it was picked up by another PC and formally closed in April due to a lack of evidence.

In the meantime, Lauren had again been assaulted at school.

Chief Superintendent Denise Worth, who joined Cheshire Police this February, said: “The first PC to deal with the October incident was quite concerned. [His] entire statement has been missed until after Lauren’s death.

“The missed opportunity was the [officers’] misunderstanding of what they had in front of them. They should have been dealing with it as harassment, not an isolated assault.”

Shortly after Lauren’s death, Cheshire Police was rated as inadequate for recording crime – a rating since improved – and Ch Supt Worth says poor record-keeping meant the dots were not connected in Lauren’s case until after her death, when extra resources were put in and Northwich residents were more forthcoming with evidence.

Coroner Peter Sigee said: “The police were aware of the ongoing incidents in which Lauren was involved by prior to her death the did not treat these as a possible offence of harassment.

“Had the police investigated as such it is likely that, after February 12, 2016, they would have had sufficient evidence to charge, prosecute and convict various of the girls who had been bullying Lauren and Libby.

“This was a missed opportunity by the police to safeguard Lauren.”

Cheshire PCC David Keane said: “This is a tragic case with the life of a bright, intelligent young woman cut short as a result of bullying. I believe we, as public services, need to do more to support victims of bullying.

“That’s why I set up Cheshire’s Anti-Bullying Commission to make recommendations to criminal justice agencies, education establishments and other public bodies in regards to how they can provide more protection for victims of bullying.

“The inquest into the death of Lauren has highlighted some improvements that Cheshire Constabulary needed to make in relation to the way it works with its partners to support victims of bullying.

“Since Lauren’s death, the Constabulary has reviewed and amended its policies and procedures that focus on bullying and harassment.

"In my role to hold the chief constable to account, I will continue to scrutinise these policies to ensure the appropriate support is in place to prevent a case like this happening again in Cheshire.”

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The University of Chester Academies Trust - failed to enact anti-bullying policy to protect Lauren

THE University of Chester Academy Northwich’s anti-bullying policy was not complied with in the build-up to Lauren Lelonek’s death, an inquest has heard.

The school, which was run by the now-dissolved University of Chester Academies Trust, failed to protect Lauren from bullies for much of her time in Year 11, until an assault was witnessed by teachers in which the teenager had her hair pulled out by another girl.

She and best friend Libby Boland had fallen out with a previous friendship group prior to Year 11, leading to a sustained period of bullying for which two girls were later convicted of harassment.

Then-UCAN principal Cath Green said: “Lauren and [best friend] Libby [Boland] wanted to focus on being successful at the end of Year 11. The others didn’t necessarily want them to be, and that was what caused the rift and the split in the group.”

Coroner Peter Sigee concluded that, prior to an assault in front of teachers in February – after which the perpetrators were taught in a separate part of the school – there was a ‘missed opportunity’ to protect Lauren and Libby.

He said: “Lauren and her best friends remained in fear. There were ongoing threats.

“The school did make efforts to protect Lauren while in school, but the threats persisted. The school did not fully comply with its anti-bullying policy, in particular prior to February 12, 2016.

“In the period prior to this date there was a missed opportunity by the school to fully consider the risk to Lauren and to implement protective measures for her.”

On one occasion, following an assault outside of school which was reported by the police, Lauren was called a ‘grass’ and ‘snitch’ for three consecutive days before eventually reacting to the goading – earning her a five-day suspension from school.

Ms Green said: “The situation was very difficult to manage. It was volatile.

“Looking back, that wasn’t the right thing to do. At the time we felt she wasn’t in control – it was based on her behaviour in that one incident. In hindsight, it was not appropriate to give that sanction at that time.”

The missed opportunities arose from inadequate record-keeping of bullying incidents, as well as a lack of follow-up interviews or minuted meetings with parents or outside bodies.

Ms Green, who left the school last year, said lessons had been learnt in regard to the voice of the child, and current principal Ana Roslan said a raft of positive changes had been made since the school was taken over by the North West Academies Trust last year.

She pointed to regular audits by external bodies, a new senior leadership team, more PSHCE lessons, learning success plans, enrichment opportunities, mental health first aiders, the use of an RCADS ‘anxiety and depression scale’, 50 new anti-bullying ambassadors and increased PCSO involvement.

Ms Roslan said: “The main lessons learned are around record-keeping and communication. Not enough people know what they needed to know to make sure she was safe.

“We are focused on catching children before they fall, rather than waiting until they fall to pick up the pieces.

“The previous policy under UCAT was one-size-fits-all. There is now a distinct focus on bullying and the child’s voice.

“The main lessons learned are around record-keeping and communication. Not enough people know what they needed to know to make sure she was safe.”

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Healthcare providers - gap in services left Lauren with no support

LAUREN Lelonek fell through the cracks of an age-defined mental health service in west Cheshire, an inquest has heard.

After being the victim of an assault, threats and goading in and out of school aged just 15, Lauren and her mum paid a visit to Daneside Medical Centre for an opinion on her low mood and self-esteem.

Although Lauren denied thoughts of self-harm, she was referred for an assessment.

Just a few months short of her 16th birthday, Lauren was deemed too old for CAMHS – a service which looks after children aged up to 16 – because doctors did not want her to have to go through another assessment within months.

Instead, she was referred to the Cheshire and Wirral Parternship’s 16-19 scheme, and turned away for being too young. She received no further support.

Dr Rachel Watts, clinical psychologist at the 16-19 service, told the inquest: “That would not happen now.”

A new ‘one-stop shop’ referral hub has since been introduced, where GPs will refer to an overall youth system rather than a specific age range.

Coroner Peter Sigee said: “There was no specialist psychiatric assessment of Lauren as a result of this referral.

“Lauren’s mother was left with an unclear understanding of the position as to further assessment and treatment.

“There was a missed opportunity at this time by the GP and mental health services to undertake a specialist assessment of Lauren’s mental health and to provide therapy or support to her.

“However, it cannot be determined what support or therapy would have been provided, or what the effect would have been.”

Mr Sigee said he was satisfied that the changes made since – and largely as a result of – Lauren’s death were sufficient.