Coroner Rules Neglect And Multi-Agency Failings Caused Death Of Vulnerable Trans Teenager In Brighton

The Senior Coroner for West Sussex, Brighton and Hove has found that neglect and multi-agency failings by social services and mental health care contributed to the death in April 2021 of 18-year-old Axel Matters, a young trans person whose birth name was Yasmin Price. Axel took his own life in a flat on Surrey Street in Brighton, shortly after his 18th birthday. The Coroner found it could not be determined if he intended to do so.

Axel was known by the services to be an exceptionally vulnerable person, and at risk of potential death from misadventure by severe self-harm or suicide. His needs were so significant that between June 2019 and January 2021 he lived in 24-hour supported accommodation.

He was first sectioned in September 2020 following a crisis and discharged in October to the care of his local Child and Adolescent Mental Health Services (CAMHS), but CAMHS discharged him after three weeks without providing any input or transitioning him to adult services. The Coroner found that this was not an appropriate response and that there should have been more assertive follow-up, as well as a plan of care and risk management.

In January 2021, after he had turned 18 and following another crisis, Axel was sectioned under the Mental Health Act and taken to Langley Green Hospital. However, in late February he showed signs of deterioration again and was involved in two incidents on the ward. On 22 February 2021, there was an unplanned discharge of Axel from Langley Green to police custody.

Social services placed Axel in emergency unsupported accommodation in Brighton, even though he had never previously lived alone. The placement was initially meant to last only seven days, but he was left there for two months prior to his death. Contrary to his Care Act 2014 care and support plan, an assessment of his capacity to make decisions in relation to his care and support and ability to live alone was never completed.

In the two months following his discharge, Axel was visited only twice by social workers, and never by mental health staff. At the in-person visits with his social workers, Axel showed visible signs of self-harm, abuse of alcohol and self-neglect, but staff did not take action such as arranging a risk assessment or mental health review.

Sadly on 23 April 2021, Axel was found hanging in his flat. It was thought by police that he had been there for a number of days.

Hayley Chapman of Hodge Jones & Allen Solicitors acted for Axel’s family. Barrister James Robottom of Matrix Chambers represented the family at the inquest.

Following an Article 2 inquest held between 25 September and 10 October 2023, the Senior Coroner ruled as follows:

On 22nd February 2021 Axel had an unplanned discharge from Hospital, following his arrest by Police, at a time when he was showing signs of a decline in his mental health. The agencies failed him in that: –

1. The Mental Health Services failed to arrange a coherent planned discharge on 22nd February 2021 and provide a clear risk, crisis and care plan on discharge.
2. Adult Social Care failed to arrange a capacity assessment upon his discharge on 22nd February 2021 or any time thereafter.
3. There was a lack of consideration by all agencies involved with Axel as to whether the accommodation provided to him was suitable for a young person, whose capacity fluctuated when in crisis, and who in those circumstances became unsafe to live alone.
4.  Axel’s Lead Practitioner from the Mental Health Service failed to assertively engage with Axel after discharge and meet with him in person. She was therefore not able to assess his ongoing risk or recognise his mental health deterioration.
5. On 6th April 2021 following an obvious decline in Axel’s mental health presentation, there was a failure by Adult Social care staff to arrange a full risk assessment and mental health review.
6. There was a lack of support and active engagement for Axel provided by the Adult Assessment and Treatment Service in Crawley pending his transfer to Adult Assessment and Treatment Service in Brighton.
7.  Axel’s death was contributed to by neglect.

The Coroner is to hand down a full ruling on the legal elements of the case, including the application of Article 2 ECHR, in due course. She has already indicated that she will be making a Regulation 28 Prevention of Future Deaths Report in relation to the failings in care provided by CAMHS.

Angela and Melvill Price, Axel’s mother and step-father, said: “We trusted professionals to provide our daughter with the right care and support but were catastrophically let down. We completely agree with the Coroner’s conclusions, but this should never have happened in the first place. We hope that no other family has to go through what we have been through. We would like to thank our legal team Hayley Chapman and Jim Robottom for their tireless work in getting accountability for Yasmin. Nothing will bring our daughter back, but we will continue to be her voice.”

Hayley Chapman, Solicitor at Hodge Jones & Allen, said: “Axel was an exceptionally vulnerable young person who clearly needed living support and mental health care in the community. Instead, he was left alone in a flat for two months. On the two occasions where Axel was visited by social services, obvious signs of deterioration were observed but no one took steps to address these. The Coroner’s finding that his death was contributed to by neglect rightly reflects how badly Axel was let down. We hope that lessons can be learned from his tragic death.”

If you have been affected by any of the issues in this article the Samaritans can be contacted on 116 123 or https://www.samaritans.org/how-we-can-help/contact-samaritan/