Opportunities were missed to save teenage terror suspect, says coroner
It emerged that Rhianan was a victim of exploitation by a right-wing extremist, but she was pronounced dead on the morning of May 19 2022 at a children's home five months after her charges were discontinued.
Concluding the inquest on Monday, chief coroner Judge Alexia Durran said the missed opportunities were 'not systemic', adding she could not be certain that Rhianan intended to take her own life.
Rhianan Rudd died at a children's home (Family handout/Leigh Day Solicitors/PA)
'I'm satisfied the missed opportunities in this case are not systemic,' Ms Durran said.
'I'm not satisfied, on the balance of probabilities, Rhianan intended to take her own life. Rhianan's death … was the result of a self-inflicted act but it is not possible to ascertain her intention.
'In the circumstances, I do not consider I should make a prevention of future deaths report.
'Rhianan was known, to family and professionals, to be vulnerable, to have autistic traits and have a history of self-harm.'
The coroner recorded Rhianan's cause of death as compression of the neck.
She added that agencies involved with her had already made changes since she died.
Rhianan's inquest, which heard evidence over four weeks in February and March, focused around the involvement of MI5, the Crown Prosecution Service (CPS), the police, social services, NHS trusts responsible for her mental health care and the children's home where she was living.
Speaking before the conclusion of the inquest, Rhianan's mother, Emily Carter, said the teenager, who was known to self harm, was a 'vulnerable child' and 'should have been treated as a victim more than anything'.
Rhianan, left, was a victim of grooming by a neo-Nazi (Family handout/Leigh Day Solicitors/PA)
Ms Carter said: 'I don't know what people thought she could do, but I don't believe that she was ever a threat. It was just what people would put in her head – brainwashed her, basically.'
The teenager was 'severely impacted' by the police investigation and 'deeply scared' about going to prison as a result of being prosecuted for terrorism, and 'locked away her thoughts and feelings' about the criminal trial.
Judge Durran concluded that it was 'necessary and appropriate' to investigate and prosecute Rhianan for terrorism offences.
She said: 'While vulnerability is a relevant factor, a difficult balance must be struck between that vulnerability and protecting the public.'
The coroner added: 'I find she was highly affected by her arrest and was concerned about being sent to prison.'
It was not known what Rhianan was told by her legal team when the charges were dropped but this may have had a 'psychological impact' on her, the coroner said.
Judge Durran decided that Article 2 of the European Convention of Human Rights was not engaged in the inquest, a decision she delayed until after she had heard all the evidence, meaning no breaches of the state's duty to protect life were identified.
The inquest conclusion heard that there were missed opportunities by counter terrorism policing East Midlands (CTPEM) and Derbyshire County Council to refer Rhianan to the National Referral Mechanism (NRM), which identifies victims of modern slavery, earlier.
Judge Durran said: 'I find, even at this early stage around November 2020, sufficient information existed for CTPEM or Derbyshire County Council to make an NRM referral.'
She said the 'combination of information available' would create a 'sufficient basis' on which to identify Rhianan as a victim of modern slavery.
The coroner added that it was not possible to say if Rhianan's charges would have been discontinued earlier or if it would have a 'more than minimal impact on Rhianan's death' if the NRM referral was made sooner.
The coroner also found there was a missed opportunity to refer Rhianan to Nottinghamshire Child and Adolescent Mental Health Services (CAMHS) when she moved to a children's home in the county.
Judge Durran said: 'Derbyshire County Council was responsible for this missed opportunity to refer Rhianan to Nottinghamshire CAMHS. As a result, Rhianan was without CAMHS support for a considerable time – effectively from May 2021 to May 2022.
'I find it was a result of individual decisions or missed opportunities to make a referral in an otherwise functioning system.'
The coroner said Rhianan did not have mental health support during a 'particularly challenging and difficult period', including her charges being dropped and the sessions with the deradicalisation programme Prevent.
But she said it was 'too speculative' to say whether CAMHS support would have made any difference.
The coroner found that Ms Carter's previous partner, who had been in prison and had a swastika tattoo, was a 'significant radicalising influence' on Rhianan.
The hearing was told that Rhianan's mother made contact with an American, Dax Mallaburn, who had convictions relating to 'violent organised crime', through a write to prisoners scheme.
Mr Mallaburn lived with Ms Carter from November 2017 and had 'links to white supremacist groups', the coroner said.
Judge Durran said: 'I'm satisfied it's more likely than not that he played a material role in introducing and encouraging Rhianan's interest in extreme, right-wing materials.'
Speaking before the conclusion of the inquest, Ms Carter said: '(Mr Mallaburn) did a lot of work in prison to be deradicalised, if you like. And so when he came out and I met him, he never showed any views.'
An American neo-Nazi, whom Rhianan spoke to online and allegedly made her send explicit photos, was also a 'significant radicalising influence', the coroner found.
The inquest heard that the CPS charged Rhianan without the 'full evidential picture' of her exploitation in April 2021 after she broke her bail conditions by running away from home to Sheffield.
The coroner said Rhianan's placement at Bluebell House Residential Home, after she was charged, was a 'positive development' in her life and the staff 'appropriately met' her needs.
Judge Durran said: 'I'm satisfied that professionals working with Rhianan were aware of her autism diagnosis. I'm entirely satisfied (staff at the children's home) were able to communicate with and support Rhianan effectively.'
The inquest heard that an MI5 investigation was 'the only way to further understand the threat she might pose to national security'.
MI5 investigated the girl from October 2020 until her death but had 'no indication' from intelligence gathered that she had intended to end her own life, an MI5 officer told the inquest.
Judge Durran said: 'Rhianan was a talented, funny and complex young person who made a lasting impression on those around her and will be deeply missed.'
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