Samuel Howes: Inquest concludes vulnerable teen’s suicide was contributed to by failures across multiple agencies 

Samuel Howes, 17, died after jumping in front of a train in Croydon on 2 September 2020, one month before his 18th birthday. The inquest into his death concluded on 30 March 2023. It found a series of missed opportunities by various agencies, including police, mental health and social services, that may have avoided his death.

Samuel had struggled with his mental health and drug dependencies and was eventually made the subject of a care order just before his 16th birthday. In the three years prior to his death, Samuel was admitted to A&E over 40 times and had 178 contacts with the police.

Two days before his death, on 30–31 August, Samuel was arrested and held in police custody. He repeatedly banged his head and attempted to tie ligatures. During the inquest, the Metropolitan Police Service (MPS) admitted that they did not request that Samuel be assessed by healthcare professionals while in custody. Identifying the approach within Croydon Custody Suite as a factor possibly contributing to Samuel’s death, the jury noted that Samuel's actions had been regarded as "attention-seeking" by police.   

Overnight on 1–2 September 2020, Samuel was recorded as a missing person. There was no active search for him. Shortly after 9am on 2 September, Samuel died.

The jury identified the response of mental health and/or social care services to Samuel’s alcohol dependency and complex needs, as a factor that had possibly contributed to Samuel’s death. They found that agencies had identified Covid as an obstacle to justify their inadequate responses. The lack of sharing of risk information between the various agencies was also highlighted as a possible contributory factor.

The Coroner will be making a report to prevent future deaths. This will address the lack of a service designed to help children presenting with a complex combination of drug and/or alcohol misuse and mental health problems.

Samuel’s family are represented by Sam Jacobs and Stephanie Davin of Doughty Street Chambers, instructed by Michael Oswald and Niamh McLoughlin of Bhatt Murphy solicitors. The family are supported by INQUEST.

More information is available in INQUEST’s press release, here. The full family statement can be found here.