Repeated serious failings in care and treatment by CAMHS contributed to death of non-binary 15-year-old | Rabah Kherbane acted as leading counsel for family of Locket Williams
Trigger warning: Suicide.
Tragically, Locket died by suicide at 00:01 hours on 28 September 2021. In the months leading up to their death, Locket had already made three serious suicide attempts. They were repeatedly failed by the Surrey and Borders Partnership NHS Foundation Trust’s Children and Adolescent Mental Health Services (“CAMHS”).
Locket Ure Williams was only 15 years old (14 years old during their first suicide attempt), and described as a lovely, vibrant, bright, articulate, and creative teenager, with a huge character. Locket preferred to use the pronouns “they” and “them”, which were used throughout the three-week inquest into their death.
At the inquest, the family were represented by Rabah Kherbane, leading Rachael Gourley (Serjeants’ Inn Chambers), and instructed by Elle Gauld at Simpson Millar. The family were supported by INQUEST.
The Senior Coroner concluded that despite three suicide attempts in a six-month period, and active CAMHS involvement recognising the required nature of treatment for Locket, “no effective treatment had been provided” in a timely manner. This more than minimally contributed to Locket’s death on their fourth suicide attempt.
The Senior Coroner also found that Locket’s death was more than minimally contributed to by CAMHS’ delay in assessing Locket’s condition and needs, and their repeated underestimation of Locket’s risk of suicide, despite the evidence before them.
In a 45-page findings and conclusions document, the Senior Coroner further recognised:
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As early as October 2020, Locket was referred by their GP to CAMHS for help due to repeated self-harm. CAMHS and its referral agency failed to respond to this in time, by which time Locket had already seriously attempted to end their life for the first time on 21 February 2021. They were admitted to hospital and discharged the next day;
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CAMHS crisis team should have contacted Locket within seven days. They failed to do so. No explanation was provided for this failure. CAMHS only contacted Locket’s family one month later after being chased by Children’s Services, on 19 March 2021;
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CAMHS repeatedly missed core group meetings with Children’s Services which provided a “pretty critical source of risk assessment information”, and by reason of their non-attendance, did not have access to this information;
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There was a failure to appreciate the high level of risk to Locket as early as April 2021, and a consequential failure to recognise that Locket needed to receive treatment quickly;
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There was a repeated underestimation in the risk to Locket, despite evidence of their suicidality. Even by this stage, Locket reported long-term and persisting suicidal ideation and there was evidence of significant psychiatric conditions. Urgent treatment was required, but none was provided or properly prioritised;
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On 21 June 2021, Locket attempted to end their life again. This attempt was a serious escalation. They wrote goodbye letters and suicide notes, which the clinicians did not ask to read when Locket was hospitalised. They told clinicians they were disappointed to still be alive. The attempt was planned over several weeks;
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Locket repeatedly expressed they required therapeutic treatment, and they were not safe at home. Locket’s parents and Children’s Services repeatedly prompted CAMHS to take appropriate action and provide treatment. Despite this, nothing changed for Locket, who “continued to wait for effective therapy to commence”;
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On 28 July 2021, Locket attempted suicide again. This represented a further escalation. They wrote suicide notes. They described in detail to police and clinicians that they had intended to end their life. Locket once more told hospital staff and CAMHS they were not safe at home. Locket was discharged home. No effective treatment was in place. Within a few weeks, CAMHS’ HOPE service care co-ordinator further discharged Locket from their care, identifying their risk to the GP as “LOW.” The Senior Coroner found “it was very difficult to see how this risk level could be justified”;
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Locket reported to CAMHS’ clinicians that they constantly thought about ending their life, and their suicidality was always present, “always there.” Locket told many professionals that they lived with persisting thoughts and urges to self-harm and take their life;
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On 28 September 2021, Locket tragically ended their life by way of suicide;
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Throughout this period, and as explored by the family during the inquest, there was a lack of continuity of care and a lack of clarity as to who was responsible for Locket’s care and who had responsibility to advocate for them. Locket was seen by at least four Consultant Psychiatrists, none of whom was the responsible clinician with the role of overseeing their care or advocating for their needs, and was also passed through multiple clinicians over the course of their engagement with CAMHS; and
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There was an underestimation of Locket’s level of risk by clinicians, which took a “wholly insufficient account of their longitudinal risk.”
Rabah represented the family from an early stage, successfully arguing that the Article 2 threshold was met in this case of suicide. This was revisited at the conclusion of the inquest, and the Senior Coroner again agreed that Article 2 was engaged because “Locket’s risk of death from suicide was a real and immediate one at the time of their death... the state were very well aware of the specific risk to Locket’s life from suicide and that there was an assumption of responsibility, by Surrey and Borders Partnership NHS Foundation Trust, in relation to that specific risk; the care which was given, and the planned CBT treatment, was intended to address the risk of suicide.”
The Senior Coroner will now require further evidence from Surrey and Borders Partnership NHS Foundation Trust’s CAMHS on Prevention of Future Deaths. The family's closing submissions addressed key issues outstanding that pose a risk of future deaths which must be addressed by the Trust.
The conclusions and findings were covered in recent Press reports here:
The full conclusions can be accessed here.
Samaritans note suicide is complex and preventable. When life is difficult, Samaritans can be contacted – day or night, 365 days a year. You can call them for free on 116 123, email them at jo@samaritans.org, or visit samaritans.org to find your nearest branch. The Papyrus HOPELINE247 on 0800 068 41 41 also provides a safe space to talk through anything happening in your life that could be impacting on your or anyone else’s ability to stay safe.