Brandon Singh Rayat · Prevention of Future Deaths report

On 10/08/2016 I commenced an investigation into the death of Brandon Singh Rayat, aged 15 years. The investigation concluded at the end of the inquest on 31 August 2017. The conclusion of the inquest was Suicide. Brandon was discovered hanging by a scarf around his neck from a hook in his wardrobe by police who had been called to his home address on the 09 August 2016. He was taken to Leicester Royal Infirmary initially but was then transferred to the Glenfield Hospital, Leicester where he died on the 10 August 2016. He had been receiving treatment from the Child and Adolescent Mental Health Service at the time of his death for low mood and anxiety. Brandon was last seen face to face by one of the treating team on the 31 May 2016 and the final contact with him was on the 03 August 2016.

Cause of Death was:-

1a) Severe Hypoxic Ischaemic Encephalopathy
1b) Strangulation by hanging

In April 2105 Brandon refused to go to school and became more and more reclusive and anxious. He was taken to the GP by his mum and he was entered into the care of the Child and Adolescent Mental Health Services. He was diagnosed with low mood and anxiety and was treated with fluoxetine. His mental health continued to deteriorate and he refused to engage with any professionals tasked with trying to assist him. His mother went to his mental health appointments alone without her son and the majority of the contact with either her or Brandon was by telephone. At times she managed to get him into the car but when they arrived at the appointment he absolutely refused to get out of the car in order to see the clinician due to his anxieties. Appointments were made appropriately by health care staff but contact with him by health professionals was via occasional telephone calls, when he agreed to speak to them. The last face to face contact with any member of the health care team was on the 31 May 2016 and his suicide occurred on the 09 August 2016. It was established that the efficacy of his care was compromised because of his lack of contact but Brandon was simply too anxious to attend out patients appointments and there was no provision or funding for the clinicians to go to Brandon’s home to treat him.

(1) That there is no provision of mental health care for children in Leicestershire who due to their anxiety are unable to attend hospital for treatment. There is a CRISIS team for children but I have been told that this cannot fulfil the function of long term treatment.