4 June 2021

Before HM Assistant Coroner Sonya Hayes
Kent and Medway Coroners Service

24 May – 4 June

Ellis Murphy-Richards was 15 years old when he died a self-inflicted death on 30 September 2020. He was under the care of NELFT Children and Adolescent Mental Health Services (CAMHS). An inquest has today concluded his death was a suicide, with the coroner highlighting a number of issues in the care he received, particularly around care planning and communication.

The coroner also raised ongoing concerns about NELFT CAMHS policies, and will be writing a report to prevent future deaths on these.

Shortly before his death, Ellis attended a counselling session with the service, during which he expressed suicidal intentions. They informed his family he should be taken to A&E, but Ellis was able to leave and walk to a location in Sheppey, Kent where he was hit by a train.

Ellis was a transgender boy who was living with his grandmother in Faversham, Kent. His death came just weeks before his sixteenth birthday. He was passionate about LGBTQ+ rights and equality. He had recently learned British Sign Language and liked to sign to pop songs.

Ellis had a history of mental ill health and had been under the care of NELFT since late 2018, specifically the Kent Children and Young People’s Mental Health Service (CYPMHS) Swale Team. During this time there were multiple incidents of serious self-harm requiring hospital care, including suicide attempts. Ellis had also been a voluntary inpatient in mental health units from February to June 2020.

Ellis was diagnosed with Other Depressive Disorders. His psychiatrist considered that he was possibly presenting with emerging Emotionally Unstable Personality Disorder, due to emotional instability and impulsive behaviour, though he did not yet have a formal diagnosis. However, Ellis’ family were not made aware of this or any diagnosis, and told the inquest they did not have support in understanding what they should be doing to help, particularly when Ellis was in crisis.

The inquest heard that, on the evening before his death, Ellis made a serious suicide attempt with a ligature at his grandmother’s house. At 10am on the day of his death, 30 September 2020, Ellis had a scheduled telephone review appointment with his psychiatrist which he attended with his grandmother. At this point she disclosed the ligature incident the night before.

The psychiatrist told the inquest that she considered this to be a serious suicide attempt. However, while she considered asking Ellis and his grandmother to go to A&E immediately, as per the safety plan, she did not do this nor did she communicate to his grandmother what the safety plan was. She was aware Ellis had another pre-scheduled appointment a few hours later with his CAMHS care coordinator. She believed they could carry out a higher quality risk assessment than one conducted by someone unknown to Ellis in A&E. Had Ellis not had this appointment she stated she would have asked them to go to A&E.

The coroner found that the psychiatrist’s actions, not instructing Ellis to be taken to hospital, was a deviation from the care plan with no assessment of the risks or communication with colleagues. While the psychiatrist did consider that Ellis may need inpatient admission, she had not built this into her deviation from the plan.

Around an hour before the appointment the psychiatrist, having been unable to contact them earlier, spoke to the care coordinator and gave some information on the suicide attempt, though not the full details. At 3pm Ellis and his grandmother attended the appointment with his care co-ordinator at Seashell’s Children’s Centre, where he communicated his intention to kill himself. The care coordinator told the inquest she believed he was at imminent risk.

The inquest heard that staff at the Seashells Children’s Centre did not have the power to restrain or detain Ellis at Seashells that day. There was no one present who could carry out a formal Mental Health Act assessment. Staff had a variable understanding of the options available in the circumstances, for example, as to whether the Crisis Team could attend a young person in the community.

The care coordinator was informed by her manager that, if Ellis did not wish to go to hospital, the police should be alerted. She was then left to deal with the situation alone, without support from other members of staff or her manager.

At or around 16:00, Ellis refused to enter the family car to go to A&E, as per the safety plan, and walked off. The NEFLT care co-ordinator and his grandmother called after him. There was nothing in the safety plan about what to do should Ellis refuse to go to A&E. Shortly after Ellis left, the care co-ordinator phoned 999 and communicated the imminent risk to Ellis’ life.

The inquest heard that CAMHS staff were aware of Ellis’ previous attempts to jump in front of trains, and relevant suicidal ideation on numerous occasions over the previous year. In spite of this, there was no headline summary in any of NELFT’s risk assessment documentation highlighting this.

Police were not informed of the risk in relation to trains. They told the inquest that, had they been aware, their response would have been different. At 16:41, Kent police were alerted to an incident on a bridge in Sheppey where a young person had jumped. Two members of the public had attempted to intervene but were unsuccessful.

After three days of evidence, the coroner gave a short form conclusion that Ellis’ death was a suicide. She also read a detailed outline of the circumstances which highlighted:

• The current care and safety plan for Ellis did not contain information on what the mental health team’s responsibilities were. There were no contingency plans for if Ellis did not cooperate.
• The care and safety plan put the emphasis on Ellis and his family to keep him safe, without clear escalation plans if this was not possible, other than attend A&E.
• It would have been appropriate to have a contingency plan in place. When the psychiatrist spoke to Ellis and his grandmother in the morning there would have been time for professionals to make a plan. The psychiatrist could have advised Ellis’ grandmother to take him to A&E from home.
• The psychiatrist reported that the emerging personality disorder may have affected Ellis’ presentation. The coroner found the family lacked information, and was not satisfied that all information which could have been shared with them, was shared.
• While the care coordinator contacted the police and highlighted the risk of suicide, the known risk around trains was not shared.

The coroner noted that Ellis did have a good relationship with some members of the mental health team, particularly his support worker. There were occasions where concerns were escalated and the safety plan worked. The coroner also found that Ellis was well supported by his close friends and family.

The coroner found that there was, prior to Ellis’ death, no written policy about what to do if a young person would attend Seashells at imminent risk, and that this is and remains the situation. She also found that no contingency plans are in place to deal with the feasible risk if a young person attends Seashells and does not want to cooperate.

The coroner will now be making a report to prevent future deaths. This will highlight the concern that the care coordinator was left to deal with the incident alone after having sought advice from a manager, as well as highlighting the lack of contingency plan, particularly when there was deviation from the safety plan with no risk assessment and limited sharing of info.

Natasha Murphy, Ellis’ mother, said: “I am disappointed that a short form conclusion was provided by the coroner. My hope and the promise, which I made to Ellis in the eulogy I read at his funeral, was to do whatever I can to make sure other young people get the support Ellis did not. I am pleased that a prevention for future deaths report will be written, although am fearful that the Trust will not change their policies to protect others or learn lessons from Ellis's death.

I am deeply saddened and angered, as in the evidence heard during the inquest, that the CAMHS psychiatrist deviated from Ellis's safety plan and had she have advised Ellis to go to A&E and he refused, that the plan could have been amended to ensure his safety on the morning of his death. I feel Ellis's death could have been prevented, like all suicides and was not inevitable. I believe that had Ellis not have attended his CAMHS appointment at seashells on the day he died, he would still be alive today.

I believe CAMHS provide a one-size-fits all service rather than what should be person centred, as Ellis had said on many occasions that the clinical treatment was not helping him. I am shocked and disgusted to hear that Ellis having suicidal ideation of jumping from railways bridges was not in his risk assessment, despite over 19 entries in the CAMHS records of this. I plan to continue to campaign for justice for Ellis with the support of INQUEST and give thanks to Taylor Rose for their support in representing me through the inquest process.”

Clare Evans of Taylor Rose MW solicitors, who represents the family, said: “The inquest has heard shocking evidence of individual and systemic failures on the part of CAMHS, including failures in contingency planning for situations when Ellis found himself in crisis and unable to keep himself safe, and the lack of a written policy dealing with young people presenting with imminent risks to end their lives. The Trust’s Serious Incident investigation report made no criticism whatsoever of the risk management planning, nor was there evidence that the Trust has implemented any changes to protect young people from the foreseeable risks in future.

The family are in no doubt that there were significant missed opportunities which could have saved Ellis’ life, and the Coroner was not sufficiently satisfied that lessons have been learned from Ellis’ death. It is hoped that the report to Prevent Future Deaths will improve the standard of care afforded to young people in the community, and ultimately, prevent the loss of other young lives.”

Bola Awogboro, caseworker at INQUEST who supports the family, said: “It is shocking that a service caring for young people with complex mental health needs has no policy for responding to children in crisis. The mental health professionals who spoke to Ellis on the day of his death knew urgent interventions were required, yet their plans were reliant on A&E, the police, and Ellis’ family. His family were given little support, information, or options to help protect him. These clear issues must be addressed urgently, not only in Kent but nationally, to ensure other young people in crisis are protected and their families are supported.”

ENDS

NOTES TO EDITORS
For further information and interview requests please contact Lucy McKay on 020 7263 1111 or [email protected]

Ellis’s family are represented by INQUEST Lawyers Group member Clare Evans of Taylor Rose MW solicitors and Rachel Barrett, Cloisters Chambers. The family are supported by INQUEST caseworker Bola Awogboro.

Other Interested Persons represented are NELFT Children and Adolescent Mental Health Services (CAMHS).

Ellis’s mother previously argued for TikTok to be involved in the inquest, as she is concerned about the impact of potentially harmful online content and the algorithms which may have increased Ellis’s access to it. However, at a pre-inquest review in January 2021 the coroner opted not to include TikTok within the scope.

Journalists should refer to the Samaritans Media Guidelines for reporting suicide and self-harm and guidance for reporting on inquests.

Trans people and mental health

Research shows that transgender people in the UK disproportionately face mental ill health, including depression and anxiety. Stonewall’s LGBT in Britain – Health report (2018) found trans people are more likely to have felt that life was not worth living, with 60% reporting these thoughts in the past year. Two thirds of trans people (67%) reported experiencing depression.