Unregulated placements and systemic failures: Lessons from the case of Nonita Grabovskyte
The death of 18-year old Nonita Grabovskyte, whose story is explored in Sky’s documentary “Unseen: A Girl Called Nonita”, exposes the profound systemic flaws within children’s social care provisions, particularly the treatment of vulnerable 16 to 18 year-olds. Nonita was a young woman, who at eighteen, was struck by a train following her repeated pleas for help to the professionals around her. For family law practitioners, this case raises critical questions about corporate parenting duties, safeguarding obligations, Children and Adolescent Mental Health Services (CAMHS) transitions and the role of inquests in scrutinising multi-agency failings.
Background: Early vulnerability and missed opportunities
Nonita was a bright young woman with a strong interest in animal behaviour and science. Behind her ambition was a long history of trauma, early childhood abuse and significant mental ill-health including self-harm, disordered eating and multiple hospital admissions. Nonita sought help from a myriad of professionals, including NHS mental health services and a local mentoring scheme. In May 2022, the London Borough of Barnet (Barnet) assumed corporate parenting responsibility following an episode of acute mental ill-health.
Key disclosures made by Nonita included:
frequent and intrusive suicidal ideation
feelings of hopelessness
the absence of any meaningful adult relationship
explicit intention to harm herself using railway lines
requests for consistent emotional support, including asking a caseworker “will you be my mummy?”
These disclosures were recorded in both NHS and local authority case notes, yet no substantive escalation of care or risk management followed.
The inquest: Scrutiny of multi-agency failures
Ciara Bartlam of Garden Court North Chambers represented Nonita on a pro bono basis. The inquest shed a stark light on the lack of coordinated safeguarding and the inadequacy of multi-agency oversight.
Interested person status (IP) and the role of advocacy organisations
Two specialist organisations, Article 39 and INQUEST, were granted Interested Person (IP) status, despite Barnet’s initial position opposing this. Their involvement proved crucial in ensuring that:
The coroner received an accurate picture of Nonita’s lived experience
Documentary evidence was properly interrogated
Systemic failings across agencies were fully explored
Their participation allowed deeper scrutiny of the decisions and omissions that preceded her death.
Disclosure failures
Material disclosed by Barnet Council, the relevant NHS Trust and her supported accommodation provider, The Singhing Tree, revealed:
Missing or incomplete mental health records
Gaps in social care logs
Limited evidence of risk assessments or escalation
Failures to follow safeguarding procedures despite explicit suicide risk disclosures and Nonita stating that she would take action to end her life by going to a railway
These omissions amounted not only to individual failings, but also highlighted structural weaknesses in how vulnerable older teenagers are monitored and supported.
Unregulated supported accommodation: A systemic weakness
When Barnet became her corporate parent, Nonita was placed in The Singhing Tree, a semi-independent supported accommodation unit for 16–18-year-olds. It was situated extremely close to a train station, something noted in local authority case records. During the inquest, further concerns became apparent:
No requirement for staff to hold specialist childcare qualifications
No regulatory oversight, as semi-independent settings for over-16s are not inspected by Ofsted
No minimum standards for care, only “support”
No increased supervision, despite disclosures that self-harm occupied “99% of her thinking”
Two weeks before her passing in December of 2023, Nonita was discharged from the CAMHS. No referral was made to adult mental health services. No housing pathway was created for her transition to adulthood. She effectively aged out of the only home she knew, with no alternative provision in place.
National context: A crisis in 16+ placements
Nonita’s experience is consistent with the wider national picture. Across England, thousands of 16-17 years olds are placed in unregulated semi-independent accommodation, characterised by:
A lack of specialist staff
Limited safeguarding
High levels of instability
Minimal oversight or accountability
Placements that would be unlawful for any child under 16
Many young people in these settings have complex needs, trauma histories and high levels of vulnerability. Research shows that young people in unregulated accommodation experience double the placement breakdowns, averaging four moves in 18 months.
These outcomes are not isolated errors, they reflect long-term structural neglect, chronic underfunding of CAMHS and a legal framework that treats 16- to 18-year-olds differently from younger children despite equivalent vulnerability.
Takeaways for family practitioners
For solicitors, barristers and social care practitioners involved in care proceedings or inquests, several key learning points arise.
Corporate parenting duties must be meaningful
Local authorities acting as corporate parents must:
Ensure emotional as well as practical support
They must avoid placing high-risk young people in unsafe settings
Escalate concerns promptly
Maintain robust documentation
Assessing the suitability of semi-independent placements
Practitioners should scrutinise:
Staff qualifications and supervision
Proximity to known self-harm locations
Risk management plans
Transition planning pre-18
Access to therapeutic support
Ensuring effective CAMHS - Adult mental health transitions
Where CAMHS discharge is anticipated, there must be:
Formal handover
Proactive referrals
Interim safety planning
Engaging with Inquest processes
Legal professionals should consider:
Early applications for IP status
Seeking full disclosure of care records
Exploring whether Article 2 is engaged
Using inquests to drive systemic learning
The reform: The Children’s Wellbeing Bill
These poor outcomes for children over the age of 16 are not the result of individual failings by the child or a single supported accommodation, but ingrained structural neglect.
Campaigners, academics, and practitioners have long-warned of the dangers of unregulated accommodation, the absence of robust aftercare, and the chronic underfunding of CAMHS.
The Children’s Wellbeing Bill proposes significant reforms including:
Strengthened corporate parenting responsibilities
Mandatory awareness across agencies of the disadvantages faced by care-experienced people
Improved safeguards for older teenagers in semi-independent accommodation
Had these principles been embedded in practice, Nonita’s path may have been profoundly different.
Conclusion: A system that must change
Across England, care leavers frequently describe experiences of instability, invisibility and systems that prioritise process over people. Nonita’s story exemplifies the same devastating concerns.
Professionals working with children for whom the state is the parent carry a vital duty to listen, advocate, challenge unsafe practice and ensure vulnerable older teenagers are not left unsupported.
At Unit Chambers, the wellbeing of every child, no matter their age, is at the heart of our practice. We challenge misconceptions of those from underrepresented backgrounds, champion access to justice and commit to supporting the next generation of diverse family pracititioners.
References
Sky, Unseen: a girl called Nonita (15 November 2025), Article 39 Founder Carolyne Willow
Law is correct as of 27th November 2025. Whilst every effort has been taken to ensure that the law in this article is correct, it is intended to give a general overview of the law for educational purposes. Readers are respectfully reminded that it is not intended to be a substitute for specific legal advice and should not be relied upon for this purpose. No liability is accepted for any error or omission contained herein.
