The suicide of a 16-year-old boy in Warwickshire, who claimed he was sexually abused, has left lessons to be learned for local agencies, a report from Warwickshire Safeguarding has revealed.

A recent investigation into the death of the boy - referred to only as Simon in the report - highlighted the "very challenging" nature of mental health support, and said improvements could be made to the way such issues are handled.

Simon was found hanged in an unnamed wood in March 2021, just hours after he had received a mental health support meeting.

Simon had received care from various agencies after he was left with a brain injury in September 2018 following a serious fall, which affected his behavior.

The child safeguarding practice review (published in September 2023) said he eventually returned to school - also not named - where he was "well supported" and "engaged well". 

But just weeks after returning to full time education, he tried to kill himself for the first time, before being found by his family.

This sparked an initial review by Warwickshire Safeguarding Partnership into how Simon could be better supported.

However, according to the report, his divorced parents did not speak fluent English, and Simon was often forced to act as a translator during his own care meetings.

While this was noted as an issue, he continued to be used as a translator rather than a professional being brought in after the review had been concluded.

It was at this time he told a social worker that he had been sexually abused by an adult, and while there was a follow up meeting for Simon, no police attended.

The report said it was clear the allegations could have been handled better.

"The lack of a strategy discussion led to an uncoordinated approach to the sexual abuse allegation which overly focused on the police led investigation and did not focus on what the trauma implications were to Simon and his health," the review said. 

"There was no clear plan on how the investigation would proceed and who would be taking the lead. 

"There was a lack of consideration of what support may be available to Simon to support him in both progressing the criminal investigation or his overall support."

Simon was eventually taken into full time hospital care, but local services could only find him a placement some 100 miles away from home which put extra strain on his family.

"The inability to access a more local provision put considerable additional pressure on the family and undoubtedly caused Simon additional concern," the report added. 

"This is a national issue."

After spending a number of months under supervision in hospital, Simon was then discharged.

On the morning of his death he had another mental health assessment.

But the report said nothing bad could be said about the meeting, and said Simon had a good relationship with his therapist.

"It would not be appropriate for this review to comment negatively on the mental health assessment that was undertaken on the day of Simon's death," the report added. 

"But the circumstances should act as a reminder to all working in this very challenging area of the changeable dynamics of a person's mental health and despite their assurance and future orientation, completed suicide is an potential outcome at almost any stage."

Read the full report here.