21 September 2016

Before HM Coroner Selena Lynch
South London Coroners Court

On 31st August 2014 Chris called for emergency help at Bethlem hospital (under the care of South London and Maudsley NHS Foundation Trust) after he had attempted suicide by swallowing objects. He suffered cardiac arrest and could not be resuscitated. He was later pronounced dead at Princess Royal University Hospital.

Chris was a 15 year old in-patient, admitted to this psychiatric hospital just six weeks earlier having swallowed batteries and bleach. At that point, his family and CAMHS felt unable to keep him safe at home. Over the previous two years, Chris’s mental health had markedly deteriorated, resulting in self-harm involving swallowing objects and a number of hospital admissions. He was under the care of Greenwich CAMHS (run by OXLEAS Trust)

The coroner concluded that cumulative failures in risk assessment and management meant neglect contributed to Chris’s death.

Notable failures by Bethlem hospital were acknowledged as significant contributors to his continued self-harming and ultimately, his death:

  • No formal, documented risk assessment was produced at any time during Chris’s six weeks in hospital.
  • No care plan existed.
  • Chris was allowed access to coins, batteries, a bottle top and a shoe lace whilst in hospital, all of which he used to self-harm.

The Coroner read out her narrative conclusion:

“Christopher suffered from mental illness and was a patient at Bethlem Adolescent Unit at the Royal Bethlem Hospital. He had a history of hearing voices, suicidal ideas, and self-harm, usually by swallowing objects. On 31st August 2014 at about 8pm, Christopher went to the communal toilet on the unit and obstructed his airway by swallowing the lid of a roll on deodorant wrapped in tissue paper. He called for help but suffered a cardiac arrest before the obstruction could be removed, and he could not be resuscitated. Christopher’s actions were in part because of cumulative and continuing failures in risk assessment and management. His death was contributed to by neglect.”

Chris’s family said:

"Losing our beloved son and brother when he was just 15 years old was so painful. Losing him as a result of the hospital's failure to protect his life is unbearable. Chris will never be forgotten and no other child should be allowed to die in this way."
Deborah Coles, Director of INQUEST said:

“Chris was an extremely vulnerable young child who was in hospital because of his high risk of self-harm and where he should have been safe. The multiple and inexcusable failings in his care allowed Chris to endanger himself many times over.

Sadly Chris’s death is not an isolated one. He is one of at least 11 child deaths of mental health in-patients INQUEST has identified between 2010 and 2014. Incredibly, we find that no single body is responsible for collating, analysing or publicising these deaths and that these deaths are not being independently investigated. The lack of resourcing of child and adolescent mental health services across the country is a national scandal.

The only possible response to this case and the growing public outcry and disquiet around mental health services for children and young people is for an urgent independent review. We call upon the Government to now take this necessary step.”

Tony Murphy from Bhatt Murphy Solicitors, acting on behalf of the Brennan family said:

”Deaths in psychiatric hospitals are not investigated by an independent body pre-inquest, which means that Coroners have to rely on evidence gathered by the very organisation  under investigation. Jeremy Hunt should not allow mental health trusts to investigate themselves in this way, not least in such a shocking death as Christopher’s”

INQUEST has been working with the family of Christopher Brennan since November 2014. The family is represented by INQUEST Lawyers Group members Tony Murphy, Bhatt Murphy Solicitors and Heather Williams QC, Doughty Street Chambers.

For further information/to arrange an interview with the family, please contact INQUEST on 020 7263 1111. Tony Murphy from Bhatt Murphy Solicitors is available for interview – please contact him direct at [email protected]

Please refer to INQUEST the organisation in all capital letters in order to distinguish it from the legal hearing.


Notes to editors:

  • Christopher Brennan is one of at least 11 child deaths of mental health in-patients INQUEST has identified over the period 2010 to 2014 through its casework and through the conduct of an extensive FOI exercise: see here
  • INQUEST met with the then Minister for Health Alistair Burt, on 21 April 2016, to discuss some of the issues raised through INQUEST’s research.


There is currently no pre-inquest system of independent investigation into the deaths of children who die as mental health in-patients. In Christopher Brennan’s case, the ‘Serious Incident Investigation’ (not yet published) reviewing the care and treatment received and the circumstances
surrounding his death was conducted by South London and Maudsley NHS Foundation Trust, who provided both the local CAMHS (run by OXLEAS Trust) care and in-patient treatment at Bethlem Hospital.


  • INQUEST’s report ‘Deaths in Mental Health Detention: An investigation framework fit for purpose?’ can be accessed here.


  • A photo of Christopher is available upon request to INQUEST.

INQUEST provides specialist advice on deaths in custody or detention or involving state failures in England and Wales. This includes a death in prison, in police custody or following police contact, in immigration detention or psychiatric care. INQUEST's policy and parliamentary work is informed by its casework and we work to ensure that the collective experiences of bereaved people underpin that work. Its overall aim is to secure an investigative process that treats bereaved families with dignity and respect; ensures accountability and disseminates the lessons learned from the investigation process in order to prevent further deaths.