9 March 2023

Before Assistant Coroner John Taylor
South London Coroner's Court, Davis House, Robert Street, Croydon CR0 1QQ
Opens 13 March 2023
Scheduled for 3 weeks

Samuel Howes was 17 years old when he died after being struck by a train in Croydon on 2 September 2020, just one month before his 18th birthday. An inquest will now examine the circumstances of his death and the care he received from various agencies including the police, health and social services, prior to his death.                                                                             

Sam was from Purley in south London. The youngest of four siblings, Sam was a much-loved son, brother, nephew, cousin and grandson. A passionate football player and big fan of Crystal Palace, Samuel was happiest when using his talents to write and perform music. His family describe him as a ‘smart, articulate and creative boy who was full of potential.’

Samuel was made the subject of a care order under London Borough of Croydon just before his 16th birthday and was living in social services semi-independent accommodation in Croydon. He was receiving mental health support from South London and Maudsley child and adolescent mental health services (SLaM CAMHS) and had complex needs.

He had a history of mental ill-health including Obsessive Compulsive Disorder, anorexia, addiction and self-harm. Samuel had been admitted to A&E over 40 times in the three years prior to his death. With the start of the Covid-19 pandemic, his mental health drastically deteriorated.

On 30 August 2020, Samuel was arrested by British Transport Police and held in police custody whilst under the influence of alcohol. During this time, he did not receive any medical attention despite repeated attempts to self-harm. He was released from custody 19 hours later without the relevant safeguarding forms having been completed.

In the evening on 1 September 2020, Samuel was recorded as a missing person by the Metropolitan Police after an incident at his accommodation. Early the next morning, Samuel contacted the London Ambulance Service (LAS) from his friend’s house whilst crying and expressing suicidal thoughts.

Police officers visited the address of his friend’s house but did not find Samuel there. Samuel’s level of risk as a missing person was classed by the police as ‘medium’ and this assessment was not escalated to high-risk. Despite this, there was no active search for Samuel. A few hours later, he died after being struck by a train at South Croydon train station.

Samuel’s family have serious questions about the care and support he received in the months leading up to his death. The Article 2 inquest will be held before a jury and will consider:

  • The care provided to Samuel in the two months before his death (from July – September 2020);whether there was any shortcoming in the mental health treatment and social services care extended to Samuel during the relevant period.
  • Contextual safeguarding between the multiple agencies involved.
  • Whether there was a service equipped to provide support to Samuel at the level he required
  • The decision-making around whether he was detainable under the Mental Health Act 1983
  • The decision-making around whether a secure placement ought to have been sought for him
  • The events leading up to 2 September 2020, when Samuel died, including broadly, whether there were any missed opportunities in the days leading up to Samuel’s death.


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

The family are represented by INQUEST Lawyers Group members Michael Oswald and Niamh McLoughlin of Bhatt Murphy solicitors and Sam Jacobs and Stephanie Davin of Doughty Street Chambers. They are supported by INQUEST senior caseworker, Jodie Anderson.

Other Interested persons represented are South London and Maudsley NHS Foundation Trust (SLAM), Croydon Social Services, Metropolitan Police Service and British Transport Police.

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