12 January 2023

Before HM Coroner Dr Sean Cummings
Bedfordshire and Luton Coroner’s Court
The Court House Woburn Street Ampthill Bedfordshire MK45 2HX
10-11 January 2023

An inquest has concluded the death of a much-loved Bedfordshire teenager, Leo Toze, was caused by suicide.

Leo was 17 years old when he died after being struck by a train after intentionally making his way onto the tracks near Biggleswade railway station in Bedfordshire in September 2021.

Before his tragic death, his family had made a series of frustrating and unsuccessful attempts to get professional support from mental health services.

Leo was a much-loved son and brother, and was exceptionally clever and able. He had been studying Maths, Further Maths and French and was due to study Maths at Warwick University.

His family describe him as “introspective and shy” with “a dry wit and clever sense of humour. He was compassionate, tolerant, articulate, polite, generous and perceptive.”

Leo had a childhood diagnosis of Autistic Spectrum Disorder. From August 2020, he was under the care of the East London NHS Foundation Trust’s (ELFT) and the Child and Adolescent Mental Health Service (CAMHS) for depression.

Leo struggled with relationships and social interactions and preferred to spend time socialising with friends online.

He attempted suicide on two occasions in January 2021. He was prescribed an anti-depressant medication and in August 2021.

The dosage was increased from 10 to 20 mg without appropriate monitoring. Suicidal ideation is a known side effect of the medication prescribed, and talking therapies proved ineffective for Leo.

On the Monday before he died, Leo posted on Twitter that he planned to take his own life. His online friends reported their concerns to the police, but the police failed to investigate or pass on the details of Leo’s social media posts to the CAMHS caring for him.

The following day (31 August 2021), a friend called 999 in the early hours after seeing messages on social media that Leo intended to take his own life that day and had made a plan.

Two Bedfordshire Police officers attended Leo’s home for a welfare check where he was at home with his mother, Revd Sharon Grenham-Thompson.

The inquest heard evidence from the officers attending Leo that they were not made aware of the nature of the plans he had set out online. As a result, they did not appreciate the seriousness of the suicide risk presented to them and could not inform Leo’s family about the increased suicide risk or respond appropriately by securing urgent medical care.

A safeguarding referral was made by the attending officers, but the crisis team did not receive the Safeguarding a Child referral at any stage.

On 31 August, Leo spoke to East London’s Crisis Team twice. Two days later, on the day before his death, Leo spoke to the team again but was assessed as low risk because they were not aware of the suicide plans he had made.

Tragically, on 3 September 2021, Leo carried out his plan and was fatally struck by a train in Biggleswade.

Missed opportunities  

The inquest heard that the police’s mental health triage services do not provide out of hours cover for members of the public. The system for the police and the East London Foundation Trust to communicate about vulnerable individuals, including children, failed as the Trust do not directly receive safeguarding referrals sent by the police.

The Coroner, Dr Sean Cummings, has called for more information from the police and East London Foundation Trust about their information sharing protocols, and about the mental health triage services provision so that he can consider whether to make any recommendations for improvement to prevent future deaths.

Speaking after the conclusion of the inquest, Leo’s mother Sharon Grenham-Thompson, said:“Nothing can ever heal the pain I feel at the loss of my son. I believe that he was let down on multiple occasions and might still be with me now if opportunities had not been missed. Leo’s death has been devastating to us as a family.

The inquest process has been extremely hard, and it strikes me that families are in a very vulnerable position throughout the process. I am grateful for the support of my legal team. We now need to take some time to recover as a family and reflect.”

Specialist solicitor Rhiannon Davies from Novum Law, who represents the family, said: “Leo was badly let down by the police and mental health services. He did not receive the emergency care he so desperately needed due to systemic failures to share information about vulnerable individuals.

While nothing can make up for the tragic loss of Leo, it’s vital that the emergency services and the NHS take steps to improve their communications in order to properly protect and care for vulnerable people, particularly children.”

Jodie Anderson, Senior Caseworker at INQUEST, said: Leo was a teenager with autism and mental health needs. He needed specialist and sustained care and support. Those who were meant to keep him safe repeatedly dismissed concerns raised by his family and failed to take them seriously. His death is one of a series of concerning deaths involving children or young adults with autism.

The lack of a multi-agency approach and many missed opportunities by multiple services point to the systemic failures that repeatedly fail children like Leo who die trying to access support. We need urgent change and investment in appropriate child-centred, autism-focused mental health support.



For further information, please contact Lucy McKay on [email protected].

The family is represented by INQUEST Lawyers Group members Rhiannon Davies of Novum Law and Martyn Hynes of 4 Breams Buildings. The family are supported by INQUEST caseworker Jodie Anderson.

Other interested persons represented are East London NHS Foundation Trust and Bedfordshire Police.

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