13 March 2023

Before HM Senior Coroner Jon Heath
North Yorkshire Coroner’s Court
Opened 12 – 27 September 2022
Resumed 23 – 25 November 2022
Concluded 13 March 2023

Ben Nelson-Roux was 16 years old when his mother, Kate, found him dead in an adult homeless hostel owned and operated by Harrogate Borough Council on 8 April 2020.

The coroner at the inquest into his death has today concluded that the medical cause of Ben’s death could not be ascertained. As a result, it was not possible to say whether Ben’s accommodation contributed to his death.

Ben’s family describe him as a normal 16-year-old child. They say he had an extraordinary zest for life but died an entirely unnecessary and preventable death. The coroner played a video pen portrait to the court which showed Ben as he was; a vivacious, adventuresome, cheeky boy who gave the best hugs.

In 2016, Ben was diagnosed with ADHD and was later recognised as a child victim of criminal exploitation. For years, Ben’s family tried to keep him safe; they tried therapy, social care, holidays and more. Tragically, the family feel the reach of Ben’s groomers outstripped his family’s resources.

In December 2019, Ben’s family turned to Children’s Social Care at North Yorkshire County Council for help. Ben’s parents could no longer keep him safe at home and his family feared that he needed state protection. The inquest heard evidence from staff at the Youth Justice Service that they felt the same.

The court decided at an early stage that there was enough evidence to suggest that the state failed to take reasonable steps to prevent a real and immediate risk to Ben’s life when he was exceptionally vulnerable.

The inquest heard evidence from over 35 witnesses across multiple agencies, most of whom were legally represented. These include North Yorkshire County Council, Harrogate Borough Council, Tees Esk and Wear Valley NHS Foundation Trust (TEWV), North Yorkshire Police, Harrogate District Hospital.

The court was unable to make a finding on the medical cause of Ben’s death because an invasive post-mortem was not carried out. According to pathologist, Dr Carl Gray, this was due to a blanket policy in North Yorkshire not to complete invasive autopsies during the early part of the first Covid lockdown.

A toxicology sample was taken but the level of drugs and alcohol in Ben’s system was too low to have caused his death. As a result, Ben’s family will never know why he died.

The coroner said he was unable to conclude that Ben’s accommodation – which all agencies accepted was unsuitable – contributed to his death because the medical cause of Ben’s death could not be ascertained.

The inquest heard evidence from independent social worker Mary Cartlidge who described a catalogue of failings, including failures to provide suitable accommodation in a therapeutic placement, to engage Ben through activities that interested him, and to ask Ben how his ADHD affected him.

The social worker described a ‘culture of institutional parent blaming’ that she identified in Ben’s case notes, with his dad being described as ‘disinterested’ and his mum being described as ‘fixated’ and ‘whipping up a frenzy’.

In her opinion, this had an impact on Ben’s care and was not borne out by the evidence given during the inquest. Rather the opposite, this was a child and family in crisis having utilised all of their resources, desperately asking for help from the state and being failed across all agencies.

The family believe the evidence disclosed to the inquest did not reflect the crisis Ben faced and gaps in the information being passed between Housing and Children’s Social Care. A hostel worker told the inquest about one serious incident on 2 March 2020 where Ben’s finger was cut off.

She told the court she had not been informed that Ben was a child in need, although she knew he was vulnerable because of his age and ‘guessed’ he had ADHD. Meanwhile, the inquest heard evidence that Ben had told his social worker that someone had threatened to cut his fingers off. Because there was no investigation into this injury, Ben’s family will never know how it was caused.

At the end of March 2020, Ben was the victim of an assault at the hostel. In evidence, the hostel worker accepted that this was not escalated as quickly as it should have been and Ben was not moved.

A witness from Housing Options told the court that alternative accommodation became available for Ben on 6 April 2020. The accommodation was in a supported environment specifically commissioned for young people and was considered ‘suitable’ for Ben in February 2020.

By April 2020, however, Ben’s needs were deemed too high for this accommodation, so he was not offered the space.

A senior mental health consultant at TEWV gave evidence that he was called two days before Ben's death, as Ben was in hospital having taken 29 diazepam tablets and cocaine.

The consultant said he called the Harrogate child and adolescent mental health service and expected to be further contacted about Ben but said “no-one called me or asked my opinion about anything”. He told the Court that “[Ben’s] basic needs were not being met and that should have alerted us to an issue.”

The general manager for the urgent care services at TEWV, told the inquest that a review was carried out into Ben's care. It found there were inconsistent appointments and limited documented evidence of a complex care plan.

Just two days before Ben died, he was deemed by CAMHS to be ‘at significant risk of death’. Despite requests from his parents for Ben to undergo a Mental Health Act assessment, one was not carried out.

The next day, Ben’s parents again raised their concerns with CAMHS about the risk that Ben might die. On the same day, Ben told his social worker that he had frequent thoughts of self-harm.

The inquest concluded that the medical cause of Ben’s death could not be ascertained and that it could not be determined that his accommodation contributed to Ben’s death.

Apart from the finding that Ben’s accommodation was unsuitable, which was described as uncontentious, the Court did not make a single critical finding.

The coroner did, however, say that he would be making a prevention of future deaths report on two issues: the failure to search for accommodation outside of North Yorkshire and the lack of rehabilitation facilities for 16 and 17 year olds who do not have a physical dependence to alcohol.

Kate Roux and Barry Nelson, Ben’s parents, said: “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. 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.”

The full family statement is available here.

Jodie Anderson, Senior Caseworker at INQUEST said: "Time and time again we see the concerns of families being ignored, and mental health, police and social services failing to communicate and meet the needs of young people like Ben.

His death will be added to the long list of children who died trying to access support. Their stories must be the wake up call that leads to proper change and investment in appropriate child-centred, individualistic mental health as well as drug and alcohol support.

This must include an urgent culture shift towards listening to family advocates, so they are no longer forced to fight for the lives of people they love.”

Gemma Vine of Ison Harrison solicitors and Ciara Bartlam of Garden Court North Chambers, who represent the family, said: “It has always been a concern of ours that an invasive post-mortem was not carried out following Ben’s death.

We feel an assumption was made that Ben had died a drug-related death and that there was an expectation that the toxicological analysis, which had not been reported before Ben’s body was released, would support that conclusion when in reality it did not. 

This was a child who had died in unsuitable, dangerous accommodation, alone, from a death that appeared on its face to have been unexplained. An investigation to discover the cause of this child’s death should have been everyone’s priority.

As a result, the coroner had no option but to record the cause of death as unascertained. There has been a missed opportunity to learn valuable lessons that could improve the accommodation and support provided to 16 and 17 year olds nationwide.

It is disappointing that the coroner did not make findings on all the centrally relevant issues which might have helped prevent future deaths.”

ENDS

NOTES TO EDITORS

For further information, please contact Leila Hagmann on [email protected].

Dying Homeless:
The Museum of Homelessness runs the Dying Homeless Project which tracks and collates the deaths of people sleeping rough as well as those placed in emergency accommodation and other insecure settings. They also host the Dying Homeless memorial, detailing the people behind the statistics.

The Dying Homeless Project found that there was a significant increase in deaths of homeless people in 2020 with 1,048 deaths, many of which took place in temporary or emergency accommodation. The number of deaths has continued to increase since.

Ben’s family are represented by INQUEST Lawyers Group members Gemma Vine of Ison Harrison solicitors and Ciara Bartlam of Garden Court North Chambers. They are supported by INQUEST caseworker Jodie Anderson.

Other interested persons are North Yorkshire Police, Harrogate and District NHS Foundation Trust, Tees Esk and Wear Valley NHS Foundation Trust, North Yorkshire County Council and Harrogate Borough Council.