Nonita Grabovskte – Barnet Council to hold extraordinary meeting

On Tuesday 2 December 2025, Barnet Council is holding an extraordinary meeting to consider the systems and structures that should be in place when an inquest is to be held into the death of a looked after child or care leaver.

This follows the inquest into the death of 18 year-old Nonita Grabovskyte, which concluded in May 2025. Last month, Sky broadcast a powerful documentary about Nonita. The documentary is available on YouTube here. It includes interviews with Article 39’s Founder and former Director, Carolyne Willow, the award-winning, care experienced actress and musician Sam Morton, and the Secretary of State for Education Bridget Phillipson MP.

Among the resolutions for this extraordinary council meeting are:

• That all Corporate Parents are immediately informed of any event involving looked after young persons which may reasonably be expected to require an inquest
• That reviews will always take place following such inquests.
• That said reviews will be published and be sent to the relevant scrutiny committee for review.
• That members should be notified of the date of any inquest in which the London Borough of Barnet is a named party.

Access the council meeting papers here.

The period leading to Nonita’s death and Article 39’s involvement in her inquest
Nonita Grabovskyte became a looked after child in May 2022, when she was 16 years old. The London Borough of Barnet was her corporate parent.

Nonita died on 28 December 2023, after being struck by a train. She was just two weeks into her adult life, having turned 18 earlier that month.

In March 2024, Article 39 was contacted by Nonita’s independent visitor, Katharine Bryson, who had serious concerns about several aspects of her life during the few months she had known her. Katharine had expressed these concerns in writing to Action for Children, the charity which managed the independent visitor scheme.

After Article 39 heard about Nonita, we approached our friends at the INQUEST charity to ask if we could work together to jointly apply to become an ‘interested person’ in Nonita’s inquest – so we could hold her corporate parent and others to account and try to bring justice for Nonita. We also hoped shining a bright light on what happened to Nonita would be a catalyst for much-needed change for other teenagers in care.

Despite having serious and sustained mental health difficulties, and a clear and consistent expressed intention to take her own life when she became an adult, at age 17 Nonita was placed by her corporate parent in supported accommodation, a home called ‘The Singhing Tree’.

By law, children in care living in this type of accommodation do not receive any day-to-day care. This is because they are deemed ready to live with a high degree of independence. Unlike children’s homes, there are no legally specified staff qualifications, no requirement for 24-hour staff presence in the accommodation, and no monthly independent safeguarding checks.

In 2021, the former government changed the law prohibiting the placement of children in care aged 15 and under in supported accommodation – what Article 39 and other campaigners for the rights of care experienced people call ‘care-less accommodation’. The same protection was not given to children in care aged 16 and 17. Article 39 legally challenged this dangerous and discriminatory change to the law. We remain bitterly disappointed that we lost that case. We co-ordinate a national campaign – #KeepCaringTo18 – to keep fighting for all children in care to receive care where they live.

In August 2024, Ofsted publicly stated that supported accommodation providers should not accept referrals from local authorities where a child has high or complex needs or requires consistent care and supervision. This was too late for Nonita, who at times was supervised on a 2:1 basis.

When Nonita first went to live at The Singhing Tree, supported accommodation was unregulated. Checks were meant to be made by local authorities, but there was no independent oversight by Ofsted.

From 28 October 2023, all supported accommodation providers (the majority are privately-run) had to be registered with Ofsted or to have submitted a full application to Ofsted.

An independent journalist, George Julian, elicited information from Ofsted after Nonita’s inquest had concluded confirming that The Singhing Tree had not submitted a full registration application by the October 2023 deadline. Ofsted told George Julian that it had “received a completed application on 31^st January 2024″.

This means that from 28 October 2023 to before Nonita turned 18, her corporate parent was paying for her to live in accommodation where the provider was operating illegally. Across this same period, the London Borough of Barnet was also acting in breach of care planning and placement regulations.

The Singhing Tree is located near a railway line. Nonita had told a mental health doctor that she would end her life by jumping on a railway track. This was known by her corporate parent. The Singhing Tree told the inquest it had never been given this information. A senior manager from The Singhing Tree also told the inquest he had never seen Nonita’s care plan. By law, this must be given to a child’s placement unless to do so would put the child at risk of significant harm.

Coroner’s conclusions and findings:

In his findings of fact, the Coroner noted that by 13 December 2023, CAMHS had decided to end its specialist mental health provision for Nonita, and she was discharged to her GP. The discharge letter said: “It is important to consider if the level of support is reduced too quicky or if she is unprepared in future for natural life transitions, self-harm will return as this is her baseline behaviours when emotionally or sensorily overwhelmed”.

The decision by CAMHS to leave Nonita without any specialist mental health support during this critical period of transition was taken before any referral was made to adult mental health services, despite her making clear she did not want the support to end and asking her specialist social worker to visit her again after their final planned visit.

The Coroner found that Nonita formed the intention to take her own life, and that the following probably made a more than minimally contribution to Nonita’s death:

1. The absence of co-ordinated transition from secondary school to college as a looked after child, resulting in Nonita not being in education for the four months leading to her 18th birthday and lacking a sense of purpose – both of which were triggers for her suicidal ideation.
2. The absence of a co-ordinated transition out of CAMHS as a highly vulnerable looked after child, leaving Nonita without any specialist mental health support from 13 December 2023 as she approached a known and dangerous crossroads in her life.
3. The absence of a co-ordinated transition out of children’s social care, resulting in several key decisions for Nonita’s future being unresolved or unconfirmed by the time of her 18^th birthday. This included funding for her residential placement, referral to adult social care, her education and immigration status. Uncertainty and isolation were known to cause Nonita distress and anxiety.
4. The absence of co-ordinated information-sharing between the various agencies involved in Nonita’s care which inhibited effective assessment and management of the risk Nonita posed to her life as she transitioned into adulthood and out of care.

Sky’s documentary notes there were 91 deaths of care leavers in England aged between 16 and 24 in the year to 31 March 2025. The official notice of this is here.

These are the deaths of care leavers known and reported by local authorities to the Department for Education. Other data published by government show that local authorities do not have basic information for around 3,000 care leavers aged 17 to 21 each year, which includes the suitability of where they are living. This suggests they are not in regular contact with these young people, or at all, despite their legal duties requiring otherwise.