Benjamin Pitt, 18, was found by police in his room at Sanctuary Supported Living, a housing facility for vulnerable youths in Linden Road, Bognor Regis, on the evening of June 7 this year.
Police were called after a staff member did not get a response from Mr Pitt’s room while doing one of two daily welfare checks. When police gained entry, they saw he had hanged himself.
Coroner Penelope Schofield asked Sanctuary area manager Miriam Reed to explain the centre’s policies after police raised concerns that the staff member did not enter the room, despite having a key.
She said national policies have been clarified so staff know they can enter a resident’s room alone if they think they are at risk. All staff dealing with young people will have training about self-harm and suicide prevention.
The area manager added that because Mr Pitt was not referred from social services, staff had no agency to contact to find him alternative accomodation, with eviction being a last resort.
She said: “We want to make sure all vulnerable people we work with get the support they need, and we don’t want to put more pressure on them, but if we do not think we can meet their needs we would do this.”
The inquest heard how Mr Pitt had a history of self-harming and suicide attempts, and his mother had contacted mental health experts about her son.
After Mr Pitt moved to the Sanctuary on April 18, a self-harming incident led staff to call mental health services and begin welfare checks.
The inquest heard evidence from Mr Pitt’s therapist Joan Carney, who saw him the day before he died. She said he seemed more positive and had applied to college.
Ms Schofield said she would file a report to the Sussex Partnership mental health trust asking it to tell Sanctuary Living if it is treating a potential resident before they move in. She said: “It needs to be reviewed, otherwise Sanctuary Living cannot support an individual properly.”
She concluded that Mr Pitt took his own life by hanging himself, with mental disorder being a contributing factor to his death.
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