Ben was a kind, funny, clever, and adventurous child.  He was a loyal friend and a deeply loved son, brother, grandson, nephew, and cousin.  He terrified us with his self-taught parkour, amazed us with magic tricks, and knew every word to every song.

Today the Court has found that the medical cause of Ben’s death cannot be ascertained because an invasive post-mortem was not carried out. As a result, we have been deprived of any answers and Ben was as failed in death as he was in life. Not only do we not know how Ben died, the Court was unable to conclude that his accommodation contributed to his death.

This is despite the fact that everyone accepted that the accommodation was not suitable for Ben’s needs. It was an adult homeless hostel. The court was told that other residents could have had serious criminal convictions and were using drugs and alcohol on the premises. The hostel warden, Jill Hayward said that she was concerned for Ben because he was only 16 and she had not seen anyone so young living there before.

The Court was told that an invasive post-mortem was not carried out because of a policy in place at the time. Our legal team is not aware of another case during 2020 where an invasive post-mortem was not carried out and particularly following the death of a child.

To us, Ben’s life was seen as less valuable because he used drugs. Because he used drugs, there was an assumption that that was the cause of his death and it stuck. There was no further investigation, which is what anyone would expect following the death of a child.

We feel that the Coroner’s conclusion did not grapple with the complexities of Ben’s case and focussed on drugs and alcohol. There was no mention of the impact of Ben being a confirmed victim of modern slavery; there was no mention of his unexplained injuries and the lack of escalation around that; there was no mention of Ben being assaulted at the hostel just a week before he died.

On the day he died, Ben’s homeless prevention worker described his accommodation as dangerous. ‘Unsuitable’ does not do it justice.

Ben had ADHD and struggled with school, which made him an easy target for criminal exploitation. Children like Ben are still vulnerable and there is not enough support to keep them, and their families, safe.

During their evidence, two Social Work Managers explained that traditionally Social Workers looked for problems within the home, and yet recently they found increasing dangers from outside the family.  It is clear that Social Work practices and culture do not reflect this change.  Systemic parent blaming undermines the family and removes vital support for children.  Social Workers need to work collaboratively with families to safeguard their children.

At the time of Ben’s death:

• There were no psychiatric beds available in the country
• There was no rehab provision for under 18s
• There was no available place of safety
• There was no suitable accommodation for a vulnerable 16 year old and the council relied on charity to provide a place for him to sleep.
• There was no procedure to support a Victim of Modern Slavery.
• He was discharged by CAMHS despite spiralling Mental Health problems and being a clear risk to himself and others.
• No tests or observations were carried out to monitor his wellbeing or organ-function after a significant overdose.
• No Child Protection Plan was in place and no safeguarding measures were undertaken.
• Our requests for a Mental Health Act Assessment were repeatedly denied.
• Our requests for a Capacity Assessment were repeatedly denied despite the impact of Ben’s disability.

We will never know the medical cause of Ben’s death because no invasive post-mortem was carried out. The Coroner’s Service has deprived us of the opportunity for answers.

We do know that he lived in fear, pain, and self-loathing for the last year of his life because, although we begged for help, no meaningful support or even basic safeguarding was put in place.

We know that this is still happening to children and families in the UK and that at the time of giving evidence, no significant changes had been made to practices or provision by the agencies involved.