17 February 2020

Before HM Coroner Anna Crawford
Surrey Coroner’s Court
10 February – 14 February 2020

An inquest into the death of James Garrard, 15, who was under the care of the Child and Adolescent Mental Health service (CAMHS) and Surrey and Borders Partnership NHS Trust has concluded that he died by hanging and that his intentions were unclear. James, from Frimley, Surrey was found hanging on Sunday 28 May 2017 and died eight days later in hospital.

A student at Tomlinscote School at the time of his death, James was a model pupil who had commenced his GCSEs. He was known amongst his friends as a happy and energetic boy, who was an active member of the Scouts, as well as a fan of karate and swimming.

The inquest heard that in October 2016 James’ family and school became concerned about his mental health and in November 2016 James was referred by his General Practitioner to CAMHS. In the months that followed his mental health and wellbeing deteriorated and James went missing on numerous occasions.

Despite this, James’ family told the inquest they felt that the extent and nature of James’ difficulties and the pressure on them was not adequately acknowledged by mental health services.   

In the few days leading up to his death, James suffered a significant decline in his mental health.   The police and mental health services attended his home on 27 May 2017, but the family believe that not enough was done to protect him.

The coroner was informed by the Trust that significant changes have been implemented in the provision of child mental health services including a requirement for on-call consultant psychiatric advice immediately after an out of hours visit and implemented a new risk rating system.

The coroner found that the care and treatment provided by the Trust to James was appropriate however she was not satisfied that an updated risk assessment had been carried out after the last visit to James prior to his death. The coroner expressed her condolences to the family and commended their extraordinary efforts to seek help for James and to keep him safe.

Speaking on behalf of the family their lawyer, Chris Callender from Simpson Millar, said: “This has been a very long journey for the family who suffered significant distress in their desperation to get James the help and services he needed and then to obtain a thorough and proper investigation in to the tragic loss of their wonderful son.

Robert Garrard, James’s father, said: The family’s aim throughout this inquest is that no other family has to experience the distress and loss we have endured. We welcome the assurances given to the coroner by the Trust that they have put in place policies and practices to reduce the chances of this happening again. The family would like to thank the coroner for the thorough investigation and providing the family the chance to fully explore the circumstances that led to their loss.