0:00:02 > 0:00:05"I want to tell you the truth about how bad things have got."
0:00:05 > 0:00:07A cry for help from a 17-year-old
0:00:07 > 0:00:11trapped within Britain's broken mental health service.
0:00:11 > 0:00:15"I came into hospital with one or two suicide plans,
0:00:15 > 0:00:17"but now I have at least five."
0:00:18 > 0:00:22Parents separated from their children by hundreds of miles.
0:00:22 > 0:00:26We shouldn't have to travel this far. There should be places nearby.
0:00:28 > 0:00:33A system so dysfunctional it can't even keep track of deaths.
0:00:33 > 0:00:36What is so shocking is that neither we
0:00:36 > 0:00:39nor the Department of Health
0:00:39 > 0:00:44know how many children are dying in psychiatric care.
0:00:44 > 0:00:46Do you know how many children have died
0:00:46 > 0:00:49in mental health units since 2010?
0:00:49 > 0:00:51I'm advised that the number is very small.
0:00:51 > 0:00:55- Well, do you know how many? - I don't know the number accurately.
0:00:55 > 0:00:58How many more deaths do they need
0:00:58 > 0:01:01before they're going to do something?
0:01:02 > 0:01:06A bereaved mother haunted by the words of her daughter.
0:01:06 > 0:01:08"I'm not all right.
0:01:08 > 0:01:10"I'm broken inside."
0:01:20 > 0:01:23Sara Green was a very bright child,
0:01:23 > 0:01:25excited about her future.
0:01:27 > 0:01:31All she ever wanted to do was go into a medical career, be a doctor.
0:01:31 > 0:01:34- Just so caring, so thoughtful.- Mm.
0:01:34 > 0:01:37You know, so much compassion for everybody else.
0:01:39 > 0:01:42Sara, more than anything, loved to write.
0:01:43 > 0:01:46"I'm hoping that I'll find out where I'm going soon,
0:01:46 > 0:01:49"so I can start looking at applying to college."
0:01:49 > 0:01:51She would write,
0:01:51 > 0:01:54and she would sometimes show us certain pages of her diary
0:01:54 > 0:01:56to let us know how she was feeling,
0:01:56 > 0:01:59if she didn't feel she could express that particular thing.
0:02:01 > 0:02:05Sara's family have allowed us to use extracts from this diary.
0:02:05 > 0:02:09A teenager writing of a broken mental health service
0:02:09 > 0:02:11and her supposed place of safety,
0:02:11 > 0:02:14the hospital where she was to die.
0:02:14 > 0:02:15"I cried so much today,
0:02:15 > 0:02:18"and I know tomorrow will be worse."
0:02:20 > 0:02:23For this film, her sister Stacey chose to read Sara's words.
0:02:25 > 0:02:28No-one could ever tell on the phone who was who.
0:02:28 > 0:02:31They'd have to say, "Is that Sara or is that Stacey?"
0:02:37 > 0:02:40Aged 11, Sara's difficulties began.
0:02:40 > 0:02:43She started developing mental health problems.
0:02:44 > 0:02:47By the time she was 14, Sara had an eating disorder
0:02:47 > 0:02:50and was locked into obsessive behaviour.
0:02:51 > 0:02:55One evening, she confided in Stacey.
0:02:55 > 0:03:00We were in our bedroom, and she told me that she self-harms.
0:03:01 > 0:03:02And I didn't...
0:03:02 > 0:03:06It was late at night, and I didn't...
0:03:06 > 0:03:09I tried not to react, really. I just listened.
0:03:11 > 0:03:12And I did say to her,
0:03:12 > 0:03:17"Well, obviously, I'm going to have to tell Mum."
0:03:17 > 0:03:19But I told her that I was glad she told me.
0:03:21 > 0:03:25Sara, like many teenagers, used self harm to show her distress.
0:03:27 > 0:03:30It led to her first brush with disaster.
0:03:32 > 0:03:35She took an overdose of antidepressants.
0:03:37 > 0:03:39"I'm not accepted at school.
0:03:39 > 0:03:42"There are only so many insults a person can take.
0:03:42 > 0:03:44"I'm hated for who I am,
0:03:44 > 0:03:46"but the truth is, I hate myself.
0:03:46 > 0:03:50"I can't believe I let them get to me like this."
0:03:51 > 0:03:54The family caught her just in time.
0:03:54 > 0:03:57They found a note. She felt bullied.
0:03:57 > 0:04:01"I want to tell you the truth about how bad things have got.
0:04:01 > 0:04:03"I'm not all right.
0:04:03 > 0:04:05"I'm broken inside."
0:04:13 > 0:04:16It's estimated nearly half of all children have been bullied.
0:04:18 > 0:04:21These days, after school ends, there's no respite.
0:04:22 > 0:04:27What we've seen is an explosion, really, around bullying.
0:04:27 > 0:04:31Cyber-bullying means that young people are exposed to bullying
0:04:31 > 0:04:3424 hours a day.
0:04:34 > 0:04:36They don't escape it at all.
0:04:36 > 0:04:39You don't come home from school and leave those people behind.
0:04:39 > 0:04:41They are still there, on your phone.
0:04:41 > 0:04:45It's having an enormous impact on young people's mental health.
0:04:47 > 0:04:49In the summer of the 2013,
0:04:49 > 0:04:51the family were living in Scunthorpe,
0:04:51 > 0:04:54and Sara was under the care of CAMHS.
0:04:56 > 0:05:00CAMHS is the Child and Adolescent Mental Health Service,
0:05:00 > 0:05:02and across England, it's in crisis.
0:05:04 > 0:05:06The Scunthorpe CAMHS office
0:05:06 > 0:05:10wasn't able to give Sara the home support she needed.
0:05:10 > 0:05:13The advice was, take her home,
0:05:13 > 0:05:16lock the windows, lock the doors,
0:05:16 > 0:05:18and if she absconds, ring the police.
0:05:20 > 0:05:22Sara took another overdose.
0:05:22 > 0:05:26Now CAMHS decided she needed hospital treatment.
0:05:26 > 0:05:29But in the whole of Humber and Yorkshire,
0:05:29 > 0:05:32there were only 30 child psychiatric beds.
0:05:32 > 0:05:34None were available.
0:05:34 > 0:05:39So for three nights, Sara was shunted between adult NHS units.
0:05:41 > 0:05:43You received a phone call, didn't you,
0:05:43 > 0:05:45giving you 20 minutes' notice that
0:05:45 > 0:05:49they were picking Sara up in a taxi from Scunthorpe
0:05:49 > 0:05:53and then going to the Priory, Cheadle Royal.
0:05:53 > 0:05:56- That's the other side of the country.- Yeah.- Yeah.
0:05:58 > 0:06:01Nearly half of all adolescent mental health patients
0:06:01 > 0:06:04are sent by the NHS to private hospitals,
0:06:04 > 0:06:07at an average cost of £800 a night.
0:06:09 > 0:06:11The Priory group, the largest provider,
0:06:11 > 0:06:13renowned for celebrity rehab,
0:06:13 > 0:06:17gets 85% of its funding from the public sector.
0:06:18 > 0:06:21On July 17th 2013,
0:06:21 > 0:06:25Sara Green was admitted to the Priory in Cheadle, Manchester.
0:06:26 > 0:06:30Now 100 miles from home and family, she turned to her diary.
0:06:30 > 0:06:33"I want to go home.
0:06:33 > 0:06:36"I just hope that Mum and Stace will be able to visit soon,
0:06:36 > 0:06:39"because it's making me feel worse not being able to see them."
0:06:41 > 0:06:45Faced with the expense of a 200-mile round trip across England,
0:06:45 > 0:06:48her family had to scrimp to see her once a fortnight.
0:06:48 > 0:06:51There was one week we lived on tuna sandwiches,
0:06:51 > 0:06:53and that is just how it was.
0:06:56 > 0:06:59That ordeal is bleakly familiar to Tara Palin.
0:07:02 > 0:07:04We met Tara this winter,
0:07:04 > 0:07:07crossing the country from Lancashire to Newcastle,
0:07:07 > 0:07:09a 300-mile round trip,
0:07:09 > 0:07:12to see her 15-year-old daughter, Rachel.
0:07:13 > 0:07:17We've tried all kinds of ways. Travelling by coach, train.
0:07:17 > 0:07:20Just... There's no real easy way.
0:07:20 > 0:07:21It's horrible.
0:07:24 > 0:07:26Rachel was a happy child.
0:07:26 > 0:07:28- Hip-hip...- Hurray!
0:07:28 > 0:07:30- Hip-hip...- Hurray!
0:07:31 > 0:07:33But like one in ten of all youngsters,
0:07:33 > 0:07:36she began having mental health problems.
0:07:41 > 0:07:44Tara, from Chorley, is one of hundreds of parents
0:07:44 > 0:07:47who must travel long distances to see their children.
0:07:47 > 0:07:49Where's she been so far, then?
0:07:49 > 0:07:53She's been to Warrington, which was not too bad.
0:07:53 > 0:07:55It felt like it was miles away,
0:07:55 > 0:07:58but it's nothing compared to now.
0:07:58 > 0:08:00And then, after that, she got moved to Stafford,
0:08:00 > 0:08:03about two-and-a-half hours away.
0:08:03 > 0:08:05And then she got moved to Middlesbrough.
0:08:05 > 0:08:07So three, three-and-a-half hours.
0:08:07 > 0:08:10- And now, well, this journey... - It's about five, isn't it?
0:08:10 > 0:08:12Yeah, takes about five hours, all in all.
0:08:12 > 0:08:14So it's getting further and further away.
0:08:14 > 0:08:16Yeah, further and further away.
0:08:17 > 0:08:20The distance leaves Tara's daughter Rachel,
0:08:20 > 0:08:23like Sara and many others before her,
0:08:23 > 0:08:27without the family support crucial to recovery.
0:08:27 > 0:08:30It's essential to try and keep young people connected
0:08:30 > 0:08:33to their communities, their families, their friends.
0:08:33 > 0:08:35That actually helps their recovery.
0:08:35 > 0:08:38CAMHS is always a Cinderella service.
0:08:38 > 0:08:43It only, even now, will be receiving 0.7%
0:08:43 > 0:08:47- of the total NHS budget. - 0.7%?- Indeed,
0:08:47 > 0:08:49of the total NHS budget.
0:08:49 > 0:08:50So we're really concerned
0:08:50 > 0:08:54that we're facing a lost generation of young people here.
0:08:56 > 0:08:58This journey isn't smooth.
0:09:01 > 0:09:05An hour's delay at Manchester - Tara is used to it.
0:09:08 > 0:09:12Tara accepts Rachel needs hospital treatment,
0:09:12 > 0:09:14but fears she's becoming institutionalised.
0:09:16 > 0:09:17She's getting worse.
0:09:17 > 0:09:20I see her with marks that she's never had before.
0:09:20 > 0:09:22Learned behaviour. That's never happened.
0:09:22 > 0:09:24Marks round her neck
0:09:24 > 0:09:27where she's tried to make ligatures. It's learned behaviour.
0:09:27 > 0:09:29Learned from being in these places,
0:09:29 > 0:09:31learned off other children, that they're doing it.
0:09:37 > 0:09:39# Happy birthday, dear Sara
0:09:39 > 0:09:41# Happy birthday to you! #
0:09:41 > 0:09:44Six weeks after admission to the Priory,
0:09:44 > 0:09:46close to the time when she should have been discharged,
0:09:46 > 0:09:50Sara Green was allowed home for her 17th birthday,
0:09:50 > 0:09:53her hair dyed red for the party.
0:09:53 > 0:09:54Make a wish.
0:09:54 > 0:09:56Make a wish.
0:09:59 > 0:10:01But then it was back to the Priory.
0:10:03 > 0:10:04Sara had been told she'd be there
0:10:04 > 0:10:08no more than eight weeks for initial assessment.
0:10:08 > 0:10:10"I've been in hospital for weeks now,
0:10:10 > 0:10:14"but I don't think that people fully understand my problems."
0:10:15 > 0:10:17But there was no move,
0:10:17 > 0:10:19and it fed her anxiety.
0:10:19 > 0:10:21"I cried so much today,
0:10:21 > 0:10:24"and I know tomorrow will be worse."
0:10:24 > 0:10:28Soon after, Sara says there was a huge letdown.
0:10:28 > 0:10:32She'd been looking forward to a break at home.
0:10:32 > 0:10:34"What a crap few days.
0:10:34 > 0:10:36"Friday, I was all ready to go home,
0:10:36 > 0:10:40"then I got told I wasn't going because there weren't any staff.
0:10:40 > 0:10:42"I absolutely hate it here."
0:10:43 > 0:10:45You don't promise a child,
0:10:45 > 0:10:48you don't let them get packed up ready to go home,
0:10:48 > 0:10:50and then just before you're ready to leave, say,
0:10:50 > 0:10:52"No, you're not going home."
0:10:54 > 0:10:58By October 2013, after two-and-a-half months in the Priory,
0:10:58 > 0:11:01all sides agreed Sara should be closer to home.
0:11:03 > 0:11:05But nothing happened.
0:11:05 > 0:11:08Sara's fixations became much worse.
0:11:10 > 0:11:13"If anything, I have worse thoughts of suicide now
0:11:13 > 0:11:15"than I did when I first came in.
0:11:15 > 0:11:18"These are getting increasingly bad at the moment."
0:11:20 > 0:11:24Sara was plagued by notions of self-destruction.
0:11:24 > 0:11:27She started having more incidents.
0:11:27 > 0:11:29- Self-harming?- Yeah.
0:11:29 > 0:11:32And more severe incidents as well.
0:11:34 > 0:11:38At case meetings, the family would be told of fruitless attempts
0:11:38 > 0:11:40by CAMHS and NHS England
0:11:40 > 0:11:43to get Sara a bed closer to home.
0:11:43 > 0:11:46Each time it was different excuses.
0:11:46 > 0:11:48They'd say a bed was becoming available,
0:11:48 > 0:11:52we're just waiting for another child to be discharged, things like that.
0:11:52 > 0:11:54And then there'd be some excuse
0:11:54 > 0:11:56why it wasn't happening.
0:11:56 > 0:11:59She felt she was just being lied to all the time.
0:12:02 > 0:12:06The family say there was palpable tension between the Priory
0:12:06 > 0:12:09and the child mental health service CAMHS,
0:12:09 > 0:12:11as they discussed what should happen next.
0:12:13 > 0:12:16In these meetings, Sara was pretty much made to sit there
0:12:16 > 0:12:20and listen to CAMHS and the Priory debating between themselves
0:12:20 > 0:12:22who's going to provide funding.
0:12:22 > 0:12:25- In front of the child, the patient? - In front of Sara.
0:12:27 > 0:12:32Christmas is tough for the 1,000 or so children who are inpatients.
0:12:32 > 0:12:35Rachel Palin has now spent her second Christmas detained,
0:12:35 > 0:12:39or sectioned, under the Mental Health Act.
0:12:39 > 0:12:41150 miles away, at home,
0:12:41 > 0:12:45her mother Tara safety-proofs the presents.
0:12:45 > 0:12:47I bought her part of a tracksuit,
0:12:47 > 0:12:50and when I wrap it up, I'll have to pull this out.
0:12:50 > 0:12:52The drawstring will have to come out,
0:12:52 > 0:12:54because she will just tie it round her neck,
0:12:54 > 0:12:57and that'll be quite hard to get off her.
0:12:57 > 0:13:00Tara goes to extraordinary lengths to protect Rachel from herself.
0:13:03 > 0:13:06I'm scared that I'm going to, potentially, be responsible
0:13:06 > 0:13:10for giving her something to hurt herself with and harm herself with.
0:13:13 > 0:13:16These same worries troubled Sara's mum Jane
0:13:16 > 0:13:18when Sara was in the Priory.
0:13:20 > 0:13:22In the run-up to Christmas 2013,
0:13:22 > 0:13:24four-and-a-half months into her stay,
0:13:24 > 0:13:28the Priory lent Sara a craft book for making bracelets.
0:13:28 > 0:13:31It was bound with wire.
0:13:31 > 0:13:33See, the thing with Sara,
0:13:33 > 0:13:37if she had an idea in her mind of something to harm herself,
0:13:37 > 0:13:40she would feel she'd have to act on it.
0:13:41 > 0:13:45She couldn't just sort of erase it from her mind.
0:13:45 > 0:13:47She felt that in order to do that,
0:13:47 > 0:13:52she would have to act out whatever it was she was thinking.
0:13:54 > 0:13:58Sara's mother and sister say a member of the Priory staff
0:13:58 > 0:14:01made an ill-judged comment about the wire binding.
0:14:01 > 0:14:04A nurse had come in the room and said to Sara,
0:14:04 > 0:14:07"You'll be all right with this, Sara?
0:14:07 > 0:14:09"You won't do owt with this, would you?"
0:14:09 > 0:14:12- You won't do anything with this?- Mm.- Meaning what?
0:14:12 > 0:14:14Use it for anything.
0:14:14 > 0:14:17And after the nurse had left the room,
0:14:17 > 0:14:21Sara said, "Well, you know, I hadn't thought of that before...
0:14:21 > 0:14:24- BOTH:- "..but I have now."
0:14:25 > 0:14:29The Priory says it does not believe this conversation happened.
0:14:30 > 0:14:33Sara was allowed home leave for Christmas,
0:14:33 > 0:14:38but on Christmas Day she was anxious at the impending departure
0:14:38 > 0:14:40of her local CAMHS caseworker.
0:14:42 > 0:14:44"From the moment I got home,
0:14:44 > 0:14:47"all I have thought about is self-harming.
0:14:47 > 0:14:50"To top it off, it looks like I'll be getting another worker.
0:14:50 > 0:14:53"She says she will still be seeing me, but I'm annoyed.
0:14:53 > 0:14:56"The whole point of her was to have one consistent worker
0:14:56 > 0:14:59"because I have been through so many."
0:15:01 > 0:15:04January 2014 was a dreadful month.
0:15:06 > 0:15:10Back in the Priory, Sara tried self-strangulation, ligatures,
0:15:10 > 0:15:12eight separate times.
0:15:12 > 0:15:16She told her mother she was frightened staff might not
0:15:16 > 0:15:20find her in time and that her self-harming could end in tragedy.
0:15:23 > 0:15:26Jane wrote a two-page letter to the Priory,
0:15:26 > 0:15:28listing a number of serious complaints.
0:15:28 > 0:15:31"There have been several incidents involving ligatures..."
0:15:31 > 0:15:33"Becoming increasingly distressed and...
0:15:33 > 0:15:36"I feel my daughter's safety and wellbeing
0:15:36 > 0:15:39"is consistently seriously compromised."
0:15:39 > 0:15:42She didn't receive a reply for three months
0:15:42 > 0:15:44and by then, it was too late.
0:15:47 > 0:15:49Sara's departing CAMHS caseworker
0:15:49 > 0:15:52also put her concerns in an e-mail to her bosses.
0:15:54 > 0:15:59"We feel that Sara is no longer being appropriately risk managed."
0:16:03 > 0:16:06Some days later, Jane received a late-night phone call
0:16:06 > 0:16:10from the Priory saying they'd forcibly cut Sara's hair
0:16:10 > 0:16:14because she was threatening to ligature with it.
0:16:14 > 0:16:17Sara was devastated.
0:16:17 > 0:16:20"There's no need to hack it off whilst I'm in restraint.
0:16:20 > 0:16:23"And my hair wasn't even around my neck at that point.
0:16:23 > 0:16:25"How is that any different to assault?"
0:16:25 > 0:16:29And Sara actually told us they'd pinned her up against the wall
0:16:29 > 0:16:32and hacked it off with ligature cutters.
0:16:32 > 0:16:34The member of staff basically said,
0:16:34 > 0:16:38"We cannot let her control like that, she has to learn."
0:16:40 > 0:16:42The Priory told Panorama
0:16:42 > 0:16:47staff had no option but to cut her hair to ensure her safety,
0:16:47 > 0:16:50following repeated attempts to ligature with it.
0:16:53 > 0:16:56Sara, unwell and struggling, was still able to make
0:16:56 > 0:17:00an acute assessment of how the system was failing her.
0:17:00 > 0:17:04She, better than anyone, understood.
0:17:04 > 0:17:06"My community team are clueless,
0:17:06 > 0:17:10"and the staff here have different opinions on what to do with me.
0:17:10 > 0:17:12"I'm just kind of stuck in the middle
0:17:12 > 0:17:15"between my CAMHS team that wants me in this unit,
0:17:15 > 0:17:18"but failing to offer enough support in the community.
0:17:18 > 0:17:21"It's making me question if anyone actually knows what
0:17:21 > 0:17:23"they are talking about."
0:17:26 > 0:17:30On the last day of January, Sara took the wire binding
0:17:30 > 0:17:34from the Priory's craft book and tried to strangle herself.
0:17:34 > 0:17:37She was saved but it was close. She needed oxygen.
0:17:39 > 0:17:42A few weeks later she wrote...
0:17:42 > 0:17:45"I don't like not knowing where I am going next
0:17:45 > 0:17:47"and not knowing anything about it.
0:17:47 > 0:17:50"Not knowing when and where makes me feel really uncertain
0:17:50 > 0:17:54"about everything, and out of control, which I absolutely hate."
0:17:57 > 0:18:00Then Sara is given hope.
0:18:00 > 0:18:03A caseworker, commissioned by NHS England,
0:18:03 > 0:18:06shows her brochures of therapeutic units.
0:18:06 > 0:18:10They talk of sending her to a new one near Leeds,
0:18:10 > 0:18:15still 50 miles from home but close enough for regular family visits.
0:18:15 > 0:18:19"I'm glad that things have moved in terms of finding me a placement.
0:18:19 > 0:18:22"I'm hoping that I'll find out where I'm going soon
0:18:22 > 0:18:25"so I can start looking at applying to college."
0:18:33 > 0:18:36What Sara didn't know is the new unit wouldn't even be open
0:18:36 > 0:18:39for another six months.
0:18:39 > 0:18:41NHS England didn't know this either.
0:18:41 > 0:18:46No-one made the basic check, a phone call, to find out.
0:18:46 > 0:18:48There was no place to go to...
0:18:48 > 0:18:53so why tell us there was? Why build Sara's hopes up?
0:18:55 > 0:18:59Sara's last home visit was in March 2014.
0:18:59 > 0:19:03She was depressed at the prospect of returning to the Priory
0:19:03 > 0:19:06but her mum says they had no option.
0:19:07 > 0:19:09She didn't want to go back.
0:19:09 > 0:19:12I didn't want her to go back, I didn't...
0:19:12 > 0:19:15I didn't want her to go back, but I knew what would happen if...
0:19:15 > 0:19:17- If she didn't. - They would section her.
0:19:17 > 0:19:21And they'd made that quite clear over the period of time
0:19:21 > 0:19:23she was in there.
0:19:25 > 0:19:27On March 18th 2014,
0:19:27 > 0:19:30the day after she went back to the Priory,
0:19:30 > 0:19:33Sara Green made a second wire ligature.
0:19:35 > 0:19:37This time she wouldn't be saved.
0:19:41 > 0:19:45At half past ten she was pronounced dead.
0:19:45 > 0:19:46She had used a wire...
0:19:49 > 0:19:51..from a spiral book...
0:19:53 > 0:19:55..and taken her own life.
0:20:06 > 0:20:10The coroner at Sara's inquest was heavily critical of the Priory.
0:20:10 > 0:20:14He concluded she hadn't intended to die, it wasn't suicide,
0:20:14 > 0:20:15she was self-harming,
0:20:15 > 0:20:19her anxiety having worsened because of her unacceptably
0:20:19 > 0:20:22prolonged stay here in the Priory,
0:20:22 > 0:20:25a hospital 100 miles from her home.
0:20:29 > 0:20:32The coroner said the ward manager's evidence
0:20:32 > 0:20:36that Sara's first wire binding ligature wasn't "a serious incident"
0:20:36 > 0:20:39was a staggering admission.
0:20:40 > 0:20:42The Priory's record-keeping was
0:20:42 > 0:20:46"deplorable, so inadequate as to risk future deaths.
0:20:46 > 0:20:49"Sara would have been safer at home."
0:20:51 > 0:20:55The Priory told Panorama the safety of patients was its first concern.
0:21:16 > 0:21:18Sara Green's death should never have happened.
0:21:18 > 0:21:21The fact that it did is absolutely appalling.
0:21:21 > 0:21:24For our society, in this day and age,
0:21:24 > 0:21:28for a young person to be in inpatient care,
0:21:28 > 0:21:33where she should be getting the best of care, to help her recover,
0:21:33 > 0:21:36to take her own life is just awful.
0:21:36 > 0:21:40And what this indicates is a whole system in collapse.
0:21:41 > 0:21:45The verdict at Sara's inquest was that both CAMHS and NHS England
0:21:45 > 0:21:49had given confusing and contradictory evidence
0:21:49 > 0:21:53and had no clear plan to get Sara out of the Priory.
0:21:54 > 0:21:57The coroner blamed the entire system for Sara's death.
0:21:59 > 0:22:03CAMHS in Scunthorpe is run by an NHS Trust.
0:22:03 > 0:22:06In Sara's case, she was supposed to be in this hospital
0:22:06 > 0:22:08for six to eight weeks. She was there for nine months.
0:22:08 > 0:22:12There was no way for her to get out because you had no facilities here.
0:22:12 > 0:22:16Absolutely. And that is absolutely to be regretted.
0:22:16 > 0:22:18There was nowhere appropriate for her to go that would have met
0:22:18 > 0:22:21her needs at the time. I fully accept that.
0:22:21 > 0:22:23Because she couldn't just be transferred
0:22:23 > 0:22:26to a normal CAMHS service locally - it would require a specialist level
0:22:26 > 0:22:29of input that was not available locally -
0:22:29 > 0:22:31hence other units were being sought out.
0:22:31 > 0:22:34- And none found.- Not at that point.
0:22:36 > 0:22:38Since Sara Green's death,
0:22:38 > 0:22:42a legal campaigning group has been working with her family.
0:22:42 > 0:22:47What has been really shocking is how difficult it is to find out
0:22:47 > 0:22:49the true picture of the number of children who are dying
0:22:49 > 0:22:53in psychiatric care. We asked a parliamentary question
0:22:53 > 0:22:56to the previous Minister, Norman Lamb,
0:22:56 > 0:23:00who told us that there had been no deaths between 2010
0:23:00 > 0:23:03and between 2014. And yet we knew from our casework
0:23:03 > 0:23:06that of course there had been deaths.
0:23:06 > 0:23:10We then were forced to conduct Freedom of Information requests,
0:23:10 > 0:23:14which have subsequently found out that there have been nine deaths.
0:23:14 > 0:23:17But, of course, Freedom of Information does not apply
0:23:17 > 0:23:20- to private providers.- So you think there could be even more deaths?
0:23:20 > 0:23:22My fear is that there could be more deaths.
0:23:22 > 0:23:26But what is so shocking is that neither we
0:23:26 > 0:23:30nor the Department of Health know how many children are dying
0:23:30 > 0:23:32in psychiatric care.
0:23:32 > 0:23:36Do you know how many children have died in mental health units
0:23:36 > 0:23:38since 2010?
0:23:38 > 0:23:41- I'm advised that the number is very small.- Do you know how many?
0:23:41 > 0:23:44I don't know the number accurately beyond...
0:23:44 > 0:23:47Your predecessor said none had died.
0:23:47 > 0:23:49- Right.- We've been told by the charity Inquest
0:23:49 > 0:23:52they've established at least nine have died.
0:23:52 > 0:23:57Well, my understanding is, actually, it was fewer than that.
0:23:57 > 0:24:00Should you not, as the minister responsible, know how many?
0:24:00 > 0:24:03I was advised it was less than that number.
0:24:03 > 0:24:08The minister later said they'd records of four deaths since 2010,
0:24:08 > 0:24:11and now they'd explore Inquest's figure of nine.
0:24:11 > 0:24:12He stated...
0:24:30 > 0:24:34Rachel's mum Tara is determined the system must change.
0:24:34 > 0:24:39She started an online petition for more localised care
0:24:39 > 0:24:41and has collected over 100,000 signatures.
0:24:43 > 0:24:46It's just amazing, we were overwhelmed by it.
0:24:46 > 0:24:48And that means you have the possibility
0:24:48 > 0:24:49of a parliamentary debate.
0:24:49 > 0:24:53Yeah, I think you need over 100,000 to be considered for a debate
0:24:53 > 0:24:55in Parliament, yeah.
0:24:55 > 0:24:58These poor children are being kept so far away from their families,
0:24:58 > 0:25:02and it doesn't help recovery, it's not helpful at all.
0:25:02 > 0:25:05It's not good for them, it's not good for the family.
0:25:08 > 0:25:12In February, a long-awaited NHS task force reported that
0:25:12 > 0:25:17England's mental health services have been chronically underfunded.
0:25:17 > 0:25:21The minister says he wants that to change.
0:25:21 > 0:25:24We're trying to increase the amount both of community provision
0:25:24 > 0:25:28and specialised care. We now have 1,400 acute beds available
0:25:28 > 0:25:31for children and young people, that's the most we've ever had.
0:25:31 > 0:25:34We've added 50 since I became the minister.
0:25:34 > 0:25:38At the same time, we have an investment of £1.4 billion
0:25:38 > 0:25:40into children's and young people's services.
0:25:43 > 0:25:46Sara Green's death carries many lessons.
0:25:46 > 0:25:49I want you to give this person a compliment, OK? When I say...
0:25:49 > 0:25:52If we're falling short in caring for the mentally ill,
0:25:52 > 0:25:54what's to be done?
0:25:54 > 0:25:57Off you go. Give each other a compliment.
0:25:57 > 0:26:01Schools are now on the front line, handling mental health problems.
0:26:01 > 0:26:05Three-quarters of mental health trusts in England cut or froze
0:26:05 > 0:26:09their CAMHS teenage mental health spending last year.
0:26:09 > 0:26:13The responsibility's been put onto schools to tackle problems
0:26:13 > 0:26:15before they take hold.
0:26:15 > 0:26:18Teachers are very well placed to actually spot
0:26:18 > 0:26:22when children are in distress or where there is change
0:26:22 > 0:26:24which might indicate a mental health problem.
0:26:24 > 0:26:29So what we have done is start a new type of programme called
0:26:29 > 0:26:30Academic Resilience.
0:26:30 > 0:26:34And this is about helping schools help the mental health
0:26:34 > 0:26:38of their pupils, and it's a completely brand-new approach.
0:26:38 > 0:26:41So when Lara logged on and she saw those comments,
0:26:41 > 0:26:43how would that have made her feel?
0:26:43 > 0:26:47The school piloting the programme was Hove Park Secondary in Sussex.
0:26:47 > 0:26:50She started to regret it, yep, she started to regret it.
0:26:50 > 0:26:51And why do you think...?
0:26:51 > 0:26:53They're talking about bullying,
0:26:53 > 0:26:58a torment for Sara Green, Rachael Palin and millions of others.
0:26:58 > 0:27:00Yeah, so it could lead to depression and self-harm.
0:27:00 > 0:27:03In what ways do you think it might...?
0:27:03 > 0:27:07Rates of teenage depression have doubled since the 1980s.
0:27:07 > 0:27:10On average, three in every classroom
0:27:10 > 0:27:13will have some kind of mental health problem.
0:27:13 > 0:27:17At Hove Park it means around 160 pupils will need help.
0:27:18 > 0:27:21Self-harming, have you had any experience of that
0:27:21 > 0:27:24or do you know any friends who self-harm?
0:27:24 > 0:27:28The school employs three full-time non-teaching staff,
0:27:28 > 0:27:31the care team, for counselling.
0:27:31 > 0:27:35It's really sad to say but I think it's become quite normal now.
0:27:35 > 0:27:39The majority of people I know personally self-harm.
0:27:47 > 0:27:50- Make a wish.- I made a wish.
0:27:51 > 0:27:54Sara Green died because she was let down
0:27:54 > 0:27:57by a broken mental health service.
0:27:57 > 0:28:01The family, in their grief, know, like Sara knew,
0:28:01 > 0:28:04she would have been far safer at home.
0:28:08 > 0:28:11Sara was frightened, you could see it in her...
0:28:11 > 0:28:14Because she knew what was going on.
0:28:14 > 0:28:17And that's what makes it really, really hard as well.
0:28:17 > 0:28:19Because she knew...
0:28:19 > 0:28:23what was happening and she couldn't do anything about it and...
0:28:23 > 0:28:25neither could anybody else.
0:28:28 > 0:28:30"Fall the floor
0:28:30 > 0:28:32"Close the door
0:28:32 > 0:28:33"I don't want to be me
0:28:33 > 0:28:35"I want to be free
0:28:35 > 0:28:38"I need some relief from all this grief
0:28:38 > 0:28:40"I know I smile
0:28:40 > 0:28:43"But I haven't felt happy for a while."