30 March 2023

Samuel was a funny, charming, bright, and articulate boy. He was a talented writer and musician, and this provided an outlet for his observations on life. He was a much-loved son, brother, nephew, cousin, and grandson. Samuel had so much potential to lead a rich and creative life.

Losing Samuel has been a crushing heartbreak, traumatic beyond our comprehension. Every day and each new experience that we encounter as a family is impacted by his loss. We are changed forever by his death.

The inquest and its long, chaotic build-up have been brutal and harrowing. Hearing evidence of Samuel’s pain, unanswered cries for help and the many missed opportunities to save him will haunt us forever. 

We appreciate that many in front-line health and social care roles cared deeply for Samuel. This didn’t always translate into proactive, tangible measures to manage his increasing risk.

Samuel needed and deserved to be safeguarded. He was spiralling, frequently in crisis and returned to self-harming. I along with many professionals feared for his life. He said he wouldn’t live to be 18. He shared with some professionals that he was considering jumping in front of a train. This wasn’t widely communicated, and our family never knew of these risks.

Measures should have been put in place to protect him and provide wrap-around care to manage his safety. Emergency services, despite daily contact, were on the periphery, unaware of his acute risks. Croydon Children’s Services, as his corporate parent, should have led this response.

The Metropolitan Police and British Transport Police should hang their heads in shame. Samuel was crying out for help in custody and severely self-harming. Multiple police officers labelled him ‘attention seeking’. He was denied mental and physical health assessments and records were recorded in error to state that they had been given.

Vital safeguarding alerts and information sharing about his condition in custody 48 hours before he died were non-existent. The culture of casual indifference and lack of accountability of both police forces is shocking.

Samuel’s last cry for help went unanswered. He called an ambulance for the first ever time stating he was suicidal, hours before his death. A robust police missing person investigation should have been initiated. Instead, he was failed. The Metropolitan Police in Croydon admitted they made zero actions to actively find him. Senior police officers on duty have taken no responsibility.

Our recommendations for change, to help safeguard and save other vulnerable young people in crisis:

  1. Complex vulnerable adolescent support needs to be on the national agenda – specialist services including joined-up substance/Mental Health support, crisis services fit for purpose, outside of A&Es.
  2. Effective and meaningful multi-agency partnership working with senior oversight, including emergency services and Emergency Departments – joined-up approaches to manage risk and rapidly respond to changes, sharing vital information quickly, and robust documented decision-making.
  3. Police training and cultural reform – suicide prevention and mental health training as a minimum for MPS and BTP custody staff. Cultural and leadership reform is urgently required in a failing Metropolitan Police Service.

We thank the Coroner and jury for their rigour, our legal team at Bhatt Murphy: Michael Oswald and Niamh McLoughlin, and Barristers Stephanie Davin and Sam Jacobs who have joined us in advocating for Samuel.