Neglect by mental health services and significant failings by Surrey County Council contribute to the death of Oskar Nash.
An inquest has concluded that 14 year old Oskar Nash died after gross failures and missed opportunities contributed to his death.
Oskar was diagnosed with Asperger syndrome and high anxiety. From age 6, he experienced periodic episodes of suicidal ideation. Despite repeat referrals made to Surrey Child and Adolescent Mental Health Services (CAMHS), Oskar’s emotional and mental health had not been subject to a clinical assessment. The inquest heard his mother asked for help from Children’s Services on repeated occasions over many years. Oskar died on train tracks near Egham on 9 January 2020.
Four months before his death, Oskar’s GP made an “urgent” referral to CAMHS. This was triaged as routine with no consideration of Oskar’s history. The Coroner found neglect in the failure by the Trust to assess Oskar in an acceptable timeframe; to undertake a risk assessment while he was in the waiting list; and in failing to obtain any updating information after three months passed since his referral. These were “gross failures individually and cumulatively”.
The Senior Coroner for Surrey, Richard Travers, said Surrey CAMHS appeared “to be more concerned with managing and reducing CAMHS lengthy waiting list, rather than addressing the needs of a child who had been referred, by a medical professional on an urgent basis, for the specialist assessment and care the service exists to provide”.
Failures by Surrey County Council Children’s Services Department also contributed to Oskar’s death. Oskar had been recognised as a Child in Need by Surrey in 2016-2017 and open for a Child and Family Assessment again in 2018-2019. A further referral in November 2019 saw him allocated for an Early Help Assessment. This was not completed before his death. His allocated Targeted Youth Support Worker failed to review his records and was not aware of his history of suicidal ideation. Oskar had a series of missing episodes and there was concern he may be subject to exploitation. Agencies were aware he had been self-harming. A strategy meeting to consider any reason to suspect he was at risk of significant harm was conducted without adequate information. The failure to escalate Oskar’s care to a registered social worker and the failure to complete any statutory assessment or to “provide any effective intervention or support” contributed to his death. The Coroner found it “ought to have been plain to Children’s Services that Oskar required support and some intervention to protect him, including from his well-documented risk of suicidal ideation”.
The Coroner added: “it is no answer to point to Oskar’s reluctance to engage; this was a well-documented consequence of his disability and it was incumbent on the service to overcome that communication barrier”.
Oskar’s Education, Health and Care Plan had not been amended since February 2017. His placement in a named special school collapsed and he transferred to a mainstream school in March 2019. The Surrey County Council Special Educational Needs Department failed to ensure his plan was updated and Oskar was placed in a school unsuitable to meet his needs. A proposed assessment by an Educational Psychologist before any transfer did not happen. A failure by both schools to share information contributed to Oskar’s death. The Coroner said: “Given Oskar’s history at his earlier schools … proper review of the information, which was readily available, would have made it clear that Oskar would not cope, and that the risk of suicidal ideation would consequently re-emerge.”
Surrey Police witnesses accepted there had been inappropriate communication with Oskar by officers. The Coroner found an “inappropriate level of reliance by Children’s Services on the police’s involvement, so far as keeping Oskar safe was concerned”. He highlighted officers’ “almost complete lack of training upon and understanding of autism.”
The local authority made reference in closing to Oskar’s mother retaining parental responsibility for him. The Coroner stressed Mrs Nash did her very best to meet her responsibilities to Oskar both through her parenting and by seeking, for his benefit and protection, the support he needed to remain safe and well. He noted her great dignity during the course of the four week inquest.
A hearing to consider prevention of future deaths will take place later this year.
For more information, a Leigh Day statement on behalf of the family is available here.