30 September 2021

Ellis Murphy-Richards was a 15 year old child when he died a self-inflicted death on 30 September 2020. One year on, his mother is speaking out to highlight a lack of action from Children and Adolescent Mental Health Services (CAMHS) in Kent, following a critical report from the coroner.

Ellis was a transgender boy who was living 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 was under the care of NELFT CAMHS. An inquest in June concluded his death was a suicide, with the coroner highlighting a number of critical issues. Shortly before his death, Ellis attended a planned counselling session with the CAMHS service at Seashells Children’s Centre, during which he expressed suicidal intentions. Staff 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.

In July Sonia Hayes, assistant coroner for Mid Kent and Medway, wrote a report to prevent future deaths on the case. She highlighted ongoing concerns that, for children under the care of CAHMS, there is no protocol or policy for those that require Mental Health Act assessment and will not voluntarily attend A&E.

The report also notes that there was no contingency plan for these circumstances in Ellis’ Safety Plan, despite his history of suicide attempts and knowledge he had tried to take his life the night before he died. On the morning of his death, the coroner also found the Trust psychiatrist deviated from the agreed Safety Plan, without an update to the risk assessment. Instead, reliance was placed on Ellis attending for his later appointment at 15:00 with a care coordinator, who had no powers to detain or restrain Ellis for his safety.

Similarly, no one else in the centre was able to complete a formal Mental Health Act Assessment or authorise detention. Ellis’ care coordinator was therefore given advice from management to call the police if he would not go to hospital. Ultimately, the lack of contingency planning around the risk that Ellis might not feel able to follow advice regarding keeping himself safe when in crisis - which materialised – left him able to leave the side of professionals and take his own life.

In a response published this week, the NELFT Trust replied to the coroner’s report dismissing criticism and saying “the Trust considers that it did comply with its safety plan for Ellis.” Police were not called until after Ellis had left the building, when it was already clear he was unlikely to comply. However, the Trust say that this was the correct contingency plan, which was followed.

While they accept “there are always elements that can be used for learning”, the Trust make no commitments to changing or developing practices to protect children in future.

Natasha Murphy, Ellis’ mother, said: “One year on, I am angered that the Trust do not seem to have learnt any lessons from what happened to Ellis, despite the coroner identifying the need for a report to prevent future deaths. I am deeply concerned that without local and national action there is a continued risk to other children.

On the day he died, Ellis did not want to go to hospital. He made this clear but, despite Ellis stating he was going to end his life to his care coordinator, other options were not explored. There was a 5-hour window for CAMHS to intervene, after the psychiatrist was made aware on the morning of Ellis’s death, that he had made a serious attempt to take his life the night before, but no contingency planning took place, despite his increased risk. It is a sad truth that those with suicidal ideation cannot always ask for or accept help.

It is clear to me that children’s mental health services should accept responsibility for implementing safeguarding measures where children do not wish to comply, and a formal policy is needed to ensure this is possible.

Ellis was under the care of CAMHS for nearly two years. As a family the only advice we were given to safeguard him was to lock away sharps and go to A&E, not how to support or understand his mental health. I believe there is a one-size-fits-all service for children’s mental healthcare and safety planning, which is failing people like Ellis.”

Lucy McKay, spokesperson for INQUEST, said: “Coroner’s do not issue reports to prevent future deaths lightly. These reports are intended to inform practice and improve policies, so lives can be better protected. It is shocking therefore that NEFLT Trust have responded to dismissively to both the coroner’s and family’s concerns.

Denial and defensiveness from mental health Trusts frustrates the opportunities inquests provide to create change. We hope the Trust will reconsider their response, and that mental health leaders nationally will consider these ongoing issues with children’s mental health services.”

Clare Evans of Taylor Rose MW solicitors, who represents the family, said: “NELFT have passed up a crucial opportunity to effect life-saving improvements to their systems. Prevention is better than cure, yet the situation remains that responses to similar high risk mental health crises will be reactive rather than proactive, leaving young lives at risk. We owe it to our children and young people to put their mental health on the same footing as physical health”.


For further information, photos 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.

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

An inquest in June 2021 concluded Ellis’ death was a suicide, with the coroner highlighting a number of issues in the care he received, particularly around care planning and communication. See the media release for further background on the circumstances of Ellis’ death. 

The Prevention of Future Deaths report and Response from NEFLT Trust head office are published on the judiciary website. Note that Ellis was transgender and had changed his name, however the judiciary site uses Ellis’ previous name. This should not be used by journalists.