A coroner has found there were individual failings to follow support processes at a school attended by a trans teenager who died after telling staff he wanted to kill himself, but said there was no “systemic failure”.
The family of Alex Dews, 13, told an inquest earlier this year he was “crying out for help and was disregarded” while he was a Year 8 pupil at Outwood Academy Shafton, in Barnsley, South Yorkshire.
On Thursday, assistant coroner Abigail Combes told the resumed inquest: “I’m satisfied that there are processes in place.
“There are absolutely identifiable individual failures of following those processes.
“These are not sufficient to amount to systemic failure.”
The coroner said she was “slightly horrified” that the school was left to make crucial decisions about which services to refer Alex to in order make sure he had the right support.
Ms Combes said she had been told how a referral to Child and Adolescent Mental Health Services (Camhs) was not made until three weeks before Alex died, because the school’s past experience was that the waiting list was so long and Camhs would dump children from this list if they were accessing services elsewhere.
She said: “This is not a position a school should be in.”
The hearing at Sheffield Coroner’s Court heard how Alex was found with serious injuries in a park in Barnsley in July 2022 and died in hospital four days later.
Earlier this year Alex’s family described how he had told them he wanted to change his name and identify as male after going to secondary school, and Outwood Shafton put him on its vulnerable register.
The coroner described how the teenager self-harmed in school in November 2021 – an incident which she said was not properly recorded by the school and should have triggered a risk assessment.
Alex made further disclosures about self-harm to a support service and, in March 2022, he wrote a letter seen by a teacher indicating that he wanted to end his life.
This triggered an accelerated referral by the school to the iSpace counselling service, in Barnsley.
The coroner noted that Alex began counselling and, at his second session, disclosed that he had attempted an overdose.
She said that he also told the deputy safeguarding lead at the school that he wanted to end his life.
The court heard that the iSpace sessions ended in May 2022 and, although a handover suggested further engagement might be useful in the future, there was no detail and no follow-up.
The coroner noted that despite there being evidence of a deterioration in Alex’s behaviour at school, there were no further incidents of self-harm or expression of suicidal intent and the school could not have assumed “there was a real or immediate threat to Alex’s life”.
Ms Combes said the school eventually decided to make a referral to Camhs in June but this was about putting in place support for the next school year rather than an immediate fear for his life.
She said that, if staff had feared for Alex’s immediate safety, they probably would have chosen another service rather than Camhs.
The coroner said she will be writing a prevention of future deaths report to organisations including the Department of Health and Social Care, about her concerns over the way referrals are made to Camhs.
She said she also had concerns about the way schools and counselling services share information.
Ms Combes said she did not have enough evidence to conclude that Alex died as a result of suicide and recorded a narrative conclusion.
She said she did not know if Alex deliberately intended to end his life when he took the steps he did in the park.
Alex’s grandmother, Susan Dews, told the inquest earlier this year: “What has happened to us has ripped us all apart and no amount of words will ever explain the emptiness and amount of pain we feel.”
In a statement written by Mrs Dews on behalf all the family and read to the court, she said: “He was not just some troubled teen, not a number lost in a system, but a scared child, struggling to come to terms with his own gender and how he could fit into society, how he was crying out for help and was disregarded.
“How he was let down and how we are now left trying to pick up the pieces of our shattered life.”
Mrs Dews said the family realised after Alex went to secondary school that “he had been battling with his own body since the age of three”.
She described how he told his family he was transgender and how he had chosen a new name.
She said: “I would have accepted Alex no matter what he was. He was my grandson and it did not matter what name or genitalia he had. We loved him no matter what.”
Mrs Dews said: “The school did very little to build any sort of rapport or understanding of Alex during the difficult time he was going through. It almost felt that as they were not used to this type of situation, it was sort of brushed to one side.”
She said: “Alex wasn’t a troubled teenager going through a fashion phase, he was a child screaming out for help and no-one would listen or offer us the help he needed.”
She added: “I just feel let down and that Alex was failed despite every attempt to get help and every cry for help that went un-listened to and unacted on.”