Danielle Waddington, the younger of two teenage girls who apparently killed themselves by jumping to their deaths last weekend, was "on the run" from a secure mental health unit when she died, The Independent on Sunday can reveal.
At only 16 years old when she fell 120 feet from a top floor window of a tower block in Southend with her 18-year-old friend Lisa Utton, Danielle should not have been on the sea front drinking, that night, but in a locked ward in nearby Basildon, Essex.
A special child protection inquiry is now to be convened, sources have confirmed, to look into why Danielle had not been in the ward receiving the treatment for her long-term psychiatric problems that doctors, social workers, friends and even Danielle herself believed that she needed.
It is understood that Danielle, a vulnerable yet popular girl given to sudden uncontrollable outbursts of temper and attempts at self-harm, had been determined to escape from the ward because she was frightened of other patients.
One line of inquiry will need to establish whether she had been given a place in a specialist children's unit, as she should have been at the age of 16, or whether she had been billeted with adults.
Inquiries at Basildon Hospital confirmed that there is no children's secure unit there, only an adult one.
"She was in a high-security ward in Basildon but really hated it because she wasn't in the child unit but with other adults," says her friend Sam Nicholls, whose flat she was staying in just before her death.
"She was only 16 and that scared her big time. Some of those people were really crazy, and Danielle wasn't a nutter so it was very harsh on her. She also really missed her friends - even though she got on really well with her carer there."
Miss Nicholls, perhaps Danielle's closest friend, went on to say that Danielle had been allowed to leave the unit a few weeks before to spend one night with her mother.
"Her mum wanted to take her home but then she thought she couldn't handle it any more, and Danielle left but didn't want to go back to the hospital. And the hospital never came to get her back."
Danielle, a pretty girl much sought after by local boys, came to stay in the cramped council flat in a grimy, crime-ridden block shared by Sam and a number of friends.
"It was nice having her here, and she really helped out looking after my friend's six- year-old kid without wanting to be paid or anything," says Sam. "But I was worried that she should have been back in Basildon. And Danielle herself really wanted help."
Sam was therefore partly relieved when at 1.45am last Sunday morning, an hour and a half before Danielle died, an ambulance was called, because her friend had became so drunk and distressed after an evening with friends outside the Monte Carlo amusement arcade.
The ambulance took Danielle in the company of her friend Lisa to Southend General Hospital, a short walk from the Cecil Court block where she lost her life. Sam says she pleaded to go too but Lisa would not let her.
"I thought the ambulance crew would take her back to Basildon as they must have known who she was. She was well known around here. If I'd been in there, instead of Lisa, I would have made sure they did," says Sam.
But the two girls were deposited at the accident and emergency department of Southend Hospital, and left alone a few minutes later without seeing a doctor.
It would then have taken them only 10 minutes to walk down the road, a broad avenue with a line of trees down the middle, to reach Cecil Court.
Sam says she has heard reports that the two girls were arguing outside the hospital, and it is certainly true that they had not known each other very long.
But Lisa, who was 18, had a lot in common with her younger companion. With a broken family, and mental health problems of her own, she "was known" to social services in the town and had recently been given a flat by them.
Danielle and Lisa were both known to the South Essex NHS Partnership Trust and to two separate offices of Essex social services.
Our campaign: what we are demanding
The Independent on Sunday is campaigning for better treatment for mentally ill people. We want significant changes to existing services and to the Mental Health Bill. Mentally ill people have a right to be heard and we will give them a voice. We are calling for:
* Mentally ill people to have the right to the most appropriate treatment when needed. This includes people in high-security hospitals, who are eligible for transfer. Such cases must be reviewed.
* Those able to make decisions about care should also have the right to refuse treatment, unless others are put at risk.
* People should not be detained unless they need treatment for their own benefit or have committed a crime.
* People should not be subject to forcible treatment once they have left hospital. Instead, we need improved, more flexible and accessible services, including the provision of mentors and sheltered accommodation, which are attractive enough to appeal to users.
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