'He was failed': Mother of teenager who took his own life says he was denied care he should have had
The mother of a teenager who took his own life in Croydon has said she warned professionals that her son was a risk to himself, but nothing was done to help him.
Samuel Howes, 17, showed signs of self harm in police custody and was admitted to A&E more than 40 times before his death.
An inquest ruled that multiple failures across mental health, police and social services may have contributed to his death.
Samuel was highlighted as a case of huge concern by social workers, the jury-led three-week inquest at South London coroner's office heard.
One social care manager had flagged concerns on their first day in the job as they considered Samuel's risk to himself so high.
Samuel’s social worker told the inquest that the sight of his self-harm at their first meeting, months before his death, had reduced her to tears.
Speaking after the inquest's conclusion, Samuel's mother, Suzanne Howes, told ITV News her son was failed by "multiple services".
'He was failed by 10, 12 people in 48-hours' - Samuel's mum, Suzanne, tells ITV News London multiple services had an opportunity to intervene
"It was 10, 12 people that failed him within a 48-hour period. And I know they have admitted those failings, but it's incredible that could happen in this day and age to one child."
She said children's complex addiction and mental health services in London were not "fit for service".
"They use an adult model of care and for under-18s the provision is really poor, especially in London, particularly in Croydon which is so poorly funded."
"Multiple professionals and myself were saying this is going to have a fatal outcome and that didn't translate into positive action, speedy action. It was 'sit and wait', and it's so frustrating that every red flag was there, especially for the last two months of his life," Ms Howes said.
"People on the ground were doing their best but there wasn't that senior escalation within in Croydon children's services - there wasn't that a multiple agency approach. There was no connection with the police, with the Ambulance Services, with British Transport Police, that you would expect."
Samuel's complex mental health needs meant he was placed in a children’s home before being housed in two semi-independent placements. Each struggled to deal with the complexity of Samuel’s needs or contain him in the community, as his mental health deteriorated and his drug taking escalated.
In her evidence at the inquest, Ms Howes told the jury: “Although Samuel was in the care system, I played a significant role in his professional network… I lived and breathed Samuel’s issues. My life revolved around them.”
Samuel was arrested by British Transport Police (BTP) on 30 August 2020, and held in police custody while under the influence of alcohol.
A BTP officer described Samuel banging his head repeatedly and self-harming so badly his clothes were confiscated.
Despite his obvious distress, Samuel was left naked on the cell floor. In his evidence the officer described this behaviour as "attention seeking" and "fairly normal".
Samuel was released from custody 20 hours later, with no mental health assessment or ongoing safeguarding referral.
On September 1, was recorded by the Met as a missing person, but the police did not look for him or send out his picture.
The next morning, Samuel called emergency services expressing suicidal thoughts, but was still classed as medium risk.
Hours later he died after being struck by a train at South Croydon station.
Ms Howes said the Met police and the BTP "hugely failed" Samuel.
"They labelled him, they denied him the care he should have had, and they never looked for him. He was either incredibly unlucky or hugely judged," she told ITV News.
In her evidence at the inquest, Ms Howes said: “Samuel's life in the last months of his life could be summed up in that one treatment room scene - mayhem, misunderstanding, trauma, judgement and heartbreak.”
Ms Howes would like to see a more joined-up approach between all agencies and better provision for young people in mental health crises, such as safe havens and crisis cafes.
After Samuel's death the Met referred itself to the police watchdog - which found five officers should receive Informal Management Action, which was undertaken. The BTP say they can also learn lessons and have invited Samuel's family to work with them to improve services.
Croydon Children's services have said after his death they commissioned a Safeguarding Practice Review.
British Transport Police said: “First and foremost, our thoughts remain with Samuel’s family as they come to terms with the sad loss of their son and the Jury’s verdict today.
"We have been open and transparent throughout the inquest process and we accept that the relevant safeguarding forms should have been completed and submitted by the officers who dealt with Samuel in custody on 30 August 2020.
"In this case, we know that the officers involved in Samuel’s care didn’t complete the safeguarding forms because they felt they didn’t have sufficient information to do so at the time – but we accept these should have been completed in a timely fashion with as much information as they had available to them in order form part of the multi-agency response. Protecting vulnerable people is one of our top priorities, and we are sorry that on this occasion we haven’t maintained the high standards we expect.
"We have made improvements to our safeguarding procedures since Samuel’s death as part of our ongoing commitment to ensuring we are always delivering the best care possible.”
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Detective Superintendent Fi Martin, South Area Command Unit, said: "Our thoughts are with Samuel's family at this time. I cannot fathom how they are feeling, having lost him at such a young age. We offer them our sincerest condolences and have offered to meet with them in person. "The death of a young person is all the more tragic when it becomes apparent that they have come into police contact and not received the high level of service we strive for day in day out. “Following today’s outcome we will now take some time to carefully consider the findings of the jury and seek to learn any lessons as part of our ongoing commitment to improving the experience of those living with mental ill-health when they come into contact with police. “Part of that work has seen us introduce a dedicated safeguarding team that provides support to custody officers across the Met by carrying out reviews of all vulnerable detainees while they are in custody. A new evidence-based risk assessment tool that considers a wider set of factors and takes a more holistic view of the individual to identify vulnerabilities has also been implemented. “Investigating missing person reports is one of the most complex areas of policing. Each case has a unique set of circumstances which needs to be assessed to ensure an appropriate and proportionate response. “Following Samuel’s death the Met’s Directorate of Professional Standards made a referral to the Independent Office for Police Conduct (IOPC), as is protocol. An independent investigation by them concluded that five officers should receive Informal Management Action. This was undertaken in November 2021. No evidence of any officer misconduct was found.”
Debbie Jones, Chair of CSCP, said: “On behalf of the Partnership, I want to express our deepest condolences to Samuel’s family for their devastating loss.“Throughout his life, Samuel was referred to many agencies but engaged with very few. Despite being surrounded by a loving family and professionals who cared for him he often felt alone.“In the six months prior to his death, the professionals who worked hard to help Samuel, often struggled to keep him safe. They were committed to helping him and were much saddened by his death.“There is much we as a partnership can learn from Samuel, and we thank his family for their brave contributions which will help agencies in supporting other young people experiencing mental health crisis.”
A spokesperson for South London and Maudsley NHS Foundation Trust said: “We would like to express our heartfelt condolences to Samuel’s family on behalf of the Trust. We understand that the loss of a loved one is a devastating experience, and we are deeply sorry for the pain and grief caused.
“We recognise that Samuel went through a lot in his life and despite having a loving family and services around him, he often felt alone. We understand that this must have been difficult for him and his loved ones.
“It deeply saddens us that despite the efforts of all professionals and multi-agency services involved, they were unable to prevent this tragedy.
“We believe that we can learn from Samuel’s experiences, and we are grateful to his family for their bravery in sharing their story with us. We are committed to taking actions on the learning and invite Samuel’s family to continue to work with us to improve services for young people. Once again, we extend our deepest sympathies to Samuel’s family during this difficult time."
Samaritans operates a 24-hour service available every day of the year, by calling 116 123. If you prefer to write down how you’re feeling, or if you’re worried about being overheard on the phone, you can email Samaritans at firstname.lastname@example.org