Advising with empathy and experience

Danger signs missed missed by agencies and police in teenage boys suicide inquest rules.


Inadequate responses from agencies, the Metropolitan Police and British Transport Police may have contributed to a teenage boy's suicide, an inquest jury found.

Samuel Howes, 17, from Purley, southeast London, died on a railway in Croydon in September 2020.

The jury concluded Samuel's mental health and use of drugs and alcohol "probably" contributed to his death.

Samuel's mother, Suzanne Howes, said she repeatedly warned professionals she feared her child was going to die, adding multiple "red flags" were missed right up to the morning of his death a month before his 18th birthday.

Samuel Howes first exhibited behavioural difficulties when he was aged nine, which led to his first referral to Child and Adolescent Mental Health Services (CAMHS). He was later diagnosed with Obsessive Compulsive Disorder (OCD) and anorexia, as well as self-harming.

By the age of 14, Samuel was using drugs to manage his anxiety. He started with cannabis and escalated to Xanax, ketamine, MDMA, cocaine and heroin, which led to several accidental overdoses.

As his mental health deteriorated, he became increasingly prone to violent outbursts and was taken into care when he was 16.

His older sister, Daisy Howes, said the family was desperate. She said: "I was worried my mum was going to get hurt but, ultimately, we were worried that he was going to hurt himself. It didn't feel like anybody was safe."

Samuel's family estimated he was supported by at least 18 services in his lifetime, although the Croydon Safeguarding Children Partnership says he "engaged with very few.”

It is estimated Samuel attended four A&E departments 10 times, and presented at police stations eight times during his final months.

Suzanne Howes added: "It was incredible that all these emergency services were involved and nobody was making that link and saying, 'what is happening? This child is chaos off the scale'. There were red flags everywhere. I was saying, 'I think my child is going to die', and professionals were saying, 'Yeah, that is a real risk'," she added.

A three-week inquest before a jury at South London Coroner's Office concluded that poor communication and information sharing between agencies and the police could have contributed to his death, as well as the way he was treated by police forces in two incidents days before his death.

The inquest heard that on 30 August 2020 Samuel was arrested by British Transport Police (BTP) and placed in a Met Police cell and repeatedly tried to harm himself, but was not offered any mental health or psychiatric help.

Staff did not fill in mandatory safeguarding forms, and some officers described his behaviour as "attention-seeking", the hearing was told.

The jury heard that two days after Samuel was arrested by BTP, he did not return to his semi-independent accommodation and was officially classed as a missing person.

Met Police officers tried to visit him after he called emergency services in tears and said he was experiencing suicidal thoughts, but the officers were unsuccessful in finding him and did not carry out an active search, the inquest was told.

The following morning, Samuel died. Suzanne Howes said: "There was nobody looking for him. There was no phone call to me. One of the saddest things is that there was a welfare person stood next to him on the platform. Had Samuel's photograph been circulated at that point or in the weeks before... there was one final opportunity."

South London and Maudsley NHS Foundation Trust said: "It deeply saddens us that despite the efforts of all professionals and multi-agency services involved, they were unable to prevent this tragedy".

Chair of Croydon Safeguarding Children Partnership, Debbie Jones, said a review had been launched following Samuel's death, adding: "There is much we as a partnership can learn from Samuel."

Assistant chief constable Charlie Doyle, of BTP, said the force had made improvements since Samuel's death and added: "Protecting vulnerable people is one of our top priorities, and we are sorry that on this occasion we haven't maintained the high standards we expect."

A Met Police spokesperson said the force would "carefully consider the findings" of the inquest and would "seek to learn any lessons.” The force's statement added that it had referred the case to the Independent Office for Police Conduct (IOPC) and that its investigation had concluded five officers should receive informal management action, which was undertaken in November 2021.

The Howes family welcomed the inquest verdict and said lessons must be learned. Suzanne Howes said: "The biggest thing for me is a collective approach, that if you had another Samuel in Croydon tomorrow, things would be done differently.

The inquest jury recorded a narrative verdict of suicide, and that "Samuel's mental health and his use of drugs and/or alcohol probably contributed to his death.

It added: "We believe that the following matters also possibly made more than minimal, trivial or negligible contributions to his death.”

These were: The inadequate response of mental health and social care services in relation to Samuel's dependency on alcohol and the possibility of a rehabilitative placement; the failure by social services and/or mental health services to adequately share risk information with each other, and with the police, and the sharing of risk information by the Met Police and/or BTP with partner agencies.

Other factors included steps taken by the Met Police to seek an assessment of Samuel's mental health by a liaison and diversion practitioner while he was in custody on 30 and 31 August 2020; an inadequate approach of staff and safeguarding processes within Croydon Custody Suite; failures by multiple agencies and the inadequate response to the 'missing persons' investigation conducted by the Met Police