14 November 2019

Before HM Senior Coroner for Inner North London
St Pancras and Poplar Coroner’s Courts
11 – 13 August and 8 November 2019

The inquest into the death of 19 year old Osman Ahmednur concluded on 8 November 2019 with the coroner finding that a failure by Camden and Islington NHS Trust contributed to his death. Osman was a refugee from Eritrea and was found hanging in local authority accommodation in Camden, London on 10 May 2018.  

Osman was detained and tortured as a child and fled Eritrea, seeking refuge. His journey to the UK, like most unaccompanied asylum seeking children (‘UASC’), was deeply traumatic. Upon arrival in 2015 he was taken into the care of Camden Social Services and was subsequently granted refugee status.

The inquest heard that in November and December 2017, two of Osman’s friends, Filmon Yemane and Alexander Tekle, died self-inflicted deaths. Both young people had arrived in the UK from Eritrea as UASC and were part of the same friendship group in London. Osman was deeply disturbed by Filmon’s death in particular and struggled to cope.  A few months later in April 2018, Osman developed psychotic symptoms and thought that the police were going to capture him and that he would be sent back to Eritrea. Osman was also deeply concerned about the welfare of his younger brother, who had been detained in Egypt, and wanted to send money to his family.

Evidence was heard that on 2 May 2018 Osman told his keyworker that a voice in his head had told him to kill himself. Osman’s college also contacted Camden Social Services to raise serious concerns about his welfare. Despite being aware of the details of Osman’s symptoms, and the two recent self-inflicted deaths of his friends, a Psychologically Informed Consultation and Training (PICT) psychologist in Camden’s Young People’s Pathway, who was advising those caring for Osman, failed to recommend a referral for an emergency mental health assessment. Instead the psychologist, who was employed by Camden and Islington NHS Trust, told the team not to panic and gave false assurances. The inquest uncovered serious problems with the PICT role, which was not well understood by any of the agencies involved or even within the NHS Trust itself.

The coroner found that the PICT psychologist made an incorrect clinical judgement and that had Osman been referred for an emergency mental health assessment it is possible that the outcome would have been different. In light of Osman’s psychotic symptoms, the coroner could not find that Osman intended to take his life.

Since Osman’s death, a fourth young Eritrean refugee from the same friendship group has taken his life. During Osman’s inquest, evidence was heard that UASC’s risk of suicide may be ten times higher than their peers and that this specific group of deaths can be characterised as a suicide ‘cluster’.  The coroner directed the London Borough of Camden to alert other local authorities in England that there may be an increased risk of suicide amongst Eritrean young people who arrived in the UK as UASC.

Osman’s parents, Ahmed Nur and Zaynib Mussa, said from Eritrea: "Our son had a future. He was smart and brilliant. We hear that in Europe people have human rights and that's why we expected Osman would be safe and well in the UK. If we had thought that Osman might not be safe in the UK, we never would have let him leave us. We are completely devastated and have not recovered from Osman's death."

Osman’s mother Zaynib said: "I wish my son had seen a doctor when he became unwell. If I had been with Osman I would have held him in my arms and taken him to a doctor - I wish he could have been looked after in the way that a mother would look after her child." 

Olivia Anness of Bhatt Murphy solicitors said: “The outcome of this inquest is an indictment of our mental health services and the ways in which we fail to look after unaccompanied asylum seeking children and young people. Osman was a child victim of torture who came to us seeking refuge. It was incumbent upon the responsible professionals within the NHS and social services to help him overcome the understandable fear with which he arrived in this country. It is a matter of shame that Osman and his family have been failed in this way.”



The family is represented by INQUEST Lawyers Group members Olivia Anness of Bhatt Murphy Solicitors and Jamie Burton and Christopher Johnson of Doughty Street Chambers.

The family continue to urge the media - and anyone sharing information pertaining to the case online - to be mindful of the Public Health England guidance on ‘Suicide Clusters and Contagion’.

For information and advice on how to safely report on self-inflicted deaths, please look at the Samaritans Media Guidelines for reporting suicide and self-harm.