Inquest finds significant failures by Mental Health Services contributed to the death of vulnerable Surrey 15-year-old

Inquest Details and Findings

At an inquest into their death, which considered whether their risk of suicide was properly recognised, monitored and addressed by relevant state agencies, Senior Coroner Richard Travers concluded that there were a number of key failures in Locket’s mental health care and treatment. These contributed to Locket’s death.

The Senior Coroner found that Locket had a known, evidenced, and long history of self-harm and suicidal ideation. This included three past suicide attempts within seven months. Locket’s high risk of suicide was underestimated by clinicians, and Locket did not receive the treatment they needed. In particular:

1. There was a delay in diagnosing Locket and in recognising their need for treatment;
2. There was a failure to assess the likely impact of a wait for treatment and whether Locket could be kept safe whilst waiting eight months for Cognitive Behavioural Therapy (‘CBT’);
3. There was a failure to commence treatment in a timely manner, given the severity of Locket’s mental health conditions and ongoing high risk of suicide;
4. There was a failure to provide Locket with any continuity of care between clinicians; 
5. There was a lack of clarity as to who was responsible for Locket and which team was responsible for advocating for Locket and their needs;
6. There was an underestimation of Locket’s level of risk by clinicians, which took a “wholly insufficient account of their longitudinal risk;” and 
7. There was a significant delay in providing Locket with CBT, which Locket was ready and willing to engage in. 

Coroner's Conclusion

The Senior Coroner concluded that these failings contributed to their death by suicide.

Whilst the public bodies contested the application of Article 2 of the European Convention on Human Rights at the conclusion of the inquest, the Senior Coroner agreed with the family that it remained engaged and that the Trust was aware of a “real and immediate” risk to Locket’s life, and that this was a risk for which the Trust had assumed responsibility.

The Senior Coroner will now require further evidence from Surrey and Borders Partnership NHS Foundation Trust’s CAMHS, addressing the issues arising at the inquest relevant to the Prevention of Future Deaths.  The Coroner has asked the Trust to address whether there is now a system in place to ensure that young people referred to CAMHS are seen and treated promptly, and that clinicians are acting in accordance with the Trust’s guidelines.

Family's Response

Commenting on the Coroner's findings, the family’s solicitor, Elle Gauld from Simpson Millar's team of Public Law Solicitors, said: “It was extremely upsetting for Locket’s family to hear of so many failings over such a sustained period, and the errors made which ultimately contributed to their death. This includes failing to assess Locket’s needs and their risk to self, as well as the failure to provide continuity of care or to commence basic therapeutic treatment.

"Given Locket’s three suicide attempts and deteriorating mental health, CAMHS’ approach repeatedly defied logic and palpable evidence of suicidality, bypassing the patient's express wishes and placing an unrealistic burden on a family already in crisis.”

Speaking of the family’s loss, Locket’s mother, Hazel Williams, expressed hope that lessons will be learned from the inquest evidence. She said: "Locket was vibrant and had a massive heart, bringing colour to everything they participated in.

“We hope the lessons learned from their death highlight the urgent need for change and prevent future tragedies. We are grateful for the thoroughness of this inquest and the potential for positive changes in managing mental health services for young people."

Locket’s older sister, Emily, added: “Even though Locket struggled to find happiness in their world, they constantly brought happiness to others. On their darkest days, they still had so much love for the people they cared about, which is why we all have different but powerful memories to hold on to.

“Hearing the coroner recognise what we have believed for three long years—that failures by CAMHS contributed to Locket’s death and ultimately meant Locket lost all hope—is heartbreaking. 

“We’re thankful for the Coroner’s respect for Locket’s identity, which was so important to them, and we sincerely hope this process will help prevent more tragic deaths like Locket’s in the future.”

Background of Locket's Case

Locket had a history of mental health difficulties, resulting in self-harming behaviours and three previous suicide attempts throughout 2021. In the months leading up to their death, they had been involved with multiple agencies, including CAMHS, Surrey Children’s Services, and The Hope Service.

During the inquest, which concluded on Friday, May 31, 2024, at Woking Coroner’s Court, the inquest, which was heard over three weeks, considered a series of failings in the care that Locket received. This included the lack of an allocated or responsible clinician and Locket being passed from service to service without proper or accurate risk assessments and without any active therapeutic treatment being commenced.

Evidence also highlighted an overemphasis on discharge from support services and care at home, and illogical conclusions that Locket was deemed “low risk” by clinicians, despite Locket's ongoing suicidal ideation and three suicide attempts in close succession.

Additionally, long waiting lists for Cognitive Behavioural Therapy (CBT) and a shortage of therapists meant that, although clinicians all agreed CBT was necessary, Locket remained at home without access to the required support and treatment, where their mental health continued to deteriorate.

Failures in communication between social services and CAMHS were also identified, leading to crucial information being missed in Locket's assessment and care. CAMHS failed to attend Core Groups meetings held by social services to protect Locket, as a vulnerable child.

Overall, Senior Coroner Richard Travers determined that (i) the delay in assessing Locket’s condition and needs, (ii) the underestimation of Locket’s risk of suicide by CAMHS, and (iii) the failure to deliver necessary therapeutic treatment in a timely manner contributed to Locket’s death. The Coroner will hear further evidence addressing the Prevention of Future Deaths, and whether Surrey County Council and Surrey and Borders Partnership Trust have made changes since Locket’s tragic death.

Legal Representation and Support

During the three week inquest, the family were represented in court by Rabah Kherbane (Doughty Street Chambers) and Rachael Gourley (Serjeants’ Inn Chambers), instructed by Elle Gauld, a Human Rights Lawyer at Simpson Millar Solicitors. The family were supported by the charity INQUEST.

Note to Editors

The family have asked for privacy at this difficult time and would prefer not to be approached directly by the press. 

For further information about the inquest, or to request images or quotes, please contact Simpson Millar’s PR Consultant: Ashlea McConnell, 07852282802, [email protected]