Care home blamed after teenagers' suicide deaths

The girls, who both had troubled backgrounds, had been missing from the unit for more than an hour before anyone realised they were gone. By the time staff raised the alarm, the girls had fallen from the bridge.

A Fatal Accident Inquiry (FAI) into their deaths found they may still have been alive if more staff had been on duty the night they disappeared and if they had been placed in more appropriate accommodation at the centre.

In a written determination, Sheriff Ruth Anderson, QC, said there should have been four members of staff on duty instead of two.

She said the girls should also have been placed on the first floor of the unit, instead of a self-contained flat on the ground floor "directly opposite an unalarmed fire exit door".

The sheriff said: "There was no accident. Both deaths were suicides.

"I had no hesitation in concluding Neve and Georgia were well aware of what they were doing. They chose on October 4, 2009, to take their own lives, although the reasons for doing so on that particular day, and together, will never be known."

Children's mental health charity YoungMinds said the determination showed lessons needed to be learned to prevent further tragedies.

Chief executive Sarah Brennan said: "We need to urgently examine how we safeguard the mental health of looked after children and young people.

"With 60% suffering from emotional and mental health problems it is vital authorities identify, prioritise and act on the complex vulnerabilities of young people in their care."

The inquiry found the girls were not suitable to be placed within the Good Shepherd Centre, an open unit run by Catholic charitable organisation Cora, due to their backgrounds and history of absconding.

Neve, from Helensburgh, Argyll and Bute, was disturbed by the loss of her 16-year-old boyfriend eight months before and tried to take her own life in the months that followed. She also had a history of self-harm known to staff.

Concerns were also raised about Georgia's mental health five years before she died, when she told social workers she was going to kill herself.

The sheriff said Georgia was also the victim of a "sustained and increasingly violent campaign of bullying by another resident" and staff should have given this proper regard.

The inquiry heard the unit's normal policy was to accommodate girls with a high risk of absconding or self-harm on the first floor, but Neve and Georgia were placed on the ground floor. It was also not equipped to accommodate children with a risk of suicide.

Despite the girls' problems, staff said both had spent a happy weekend with relatives before they died.

Neve had returned to the centre from a weekend on home leave with her mother. Georgia had been out for a meal with her aunt in the afternoon and "gave the impression of having enjoyed her time out" after being dropped back at the centre at 7.10pm on the day of their death.

They were last seen by care worker Mary Stewart in their pyjamas at around 7.30pm, but were then captured on CCTV leaving the unit at 7.43pm.

Sheriff Anderson said: "At around 8.50pm, it was discovered Neve and Georgia were missing. Their night clothes were found lying on the floor of the bedroom.

"By the time it was appreciated the girls had absconded, they had fallen to their deaths from the Erskine Bridge. Their absence from the open unit had gone undetected for approximately one hour and 10 minutes."

She said there was a need for a "more robust approach" to security at the open unit, which has since closed. Cora continues to run Good Shepherd secure and close support units in Bishopton.

l For help, contact Breathing Space 0800 83 85 87, Samaritans 08457 90 90 90, or ChildLine 0800 11 11