Sam Michael Carl Grant · Prevention of Future Deaths report

On 13/11/2018 I commenced an investigation into the death of aged Sam Michael Carl Grant aged 16.

The investigation concluded at the end of the inquest on 28/06/2019. The medical cause of death was:

1a Hanging from ligature around the neck

Sam died on 09/11/2018 at home ████████ Milton Keynes having been found hanging by the neck by his sister on her return from school. Sam had been engaged with COMPASS services through a school referral. He had been referred to CAMHS in May 2018 but did not meet the threshold for engagement. His GP suggested other organisations who Sam could approach voluntarily for support, but he did not take up these suggestions.

1) Sam’s GP referred Sam to CAMHS when he presented to the GP with irritability, anger and a report that he was close to being excluded from school. CAMHS rejected the referral because Sam did not meet their threshold of moderate to severe mental health issues. CAMHS did not suggest any alternative assistance. The GP did follow up with Sam to sign post him to two independent organisations who Sam would have to approach independently for help. The GP made it clear in his evidence that there is a lack of lower level assistance for young people who present with ‘life issues’ such as low mood, irritability and anger issues, but who nonetheless need help and assistance but do not meet the criteria for access to CAMHS services.

2) Sam had been referred to, and was receiving the services of COMPASS having been referred by his School. The GP was not made aware of this engagement and was unable to take this into account at the time when Sam did present himself to the GP. The evidence from COMPASS is that they maintain the confidentiality of patients even minors using their services unless they have express consent to disclose that information from the patient themselves. Without all relevant information neither the GP nor CAMHS was in a position to make a fully informed decision about the Sam’s needs. Sharing of information between relevant health agencies to ensure fully informed decisions are made as regards the healthcare needs of an individual should be a priority.

3) Evidence at the inquest from the GP also indicated that a reduction in healthcare provision at Sam’s school and in particular the removal of a medically qualified person(s) has meant that confidential health information is no longer shared between the school and the GP surgery. The school now only engages First Aiders, who are not medically qualified, and who do not therefore exchange information which in the past has proved essential in flagging concerns between the GP and the School. This is another route which has been closed and which would have allowed a potential flag to have been raised in respect of concerns around Sam and his wellbeing to be shared confidentially between GP and school.

2) Sam had been referred to, and was receiving the services of COMPASS having been referred by his School. The GP was not made aware of this engagement and was unable to take this into account at the time when Sam did present himself to the GP. The evidence from COMPASS is that they maintain the confidentiality of patients even minors using their services unless they have express consent to disclose that information from the patient themselves. Without all relevant information neither the GP nor CAMHS was in a position to make a fully informed decision about the Sam’s needs. Sharing of information between relevant health agencies to ensure fully informed decisions are made as regards the healthcare needs of an individual should be a priority.

3) Evidence at the inquest from the GP also indicated that a reduction in healthcare provision at Sam’s school and in particular the removal of a medically qualified person(s) has meant that confidential health information is no longer shared between the school and the GP surgery. The school now only engages First Aiders, who are not medically qualified, and who do not therefore exchange information which in the past has proved essential in flagging concerns between the GP and the School. This is another route which has been closed and which would have allowed a potential flag to have been raised in respect of concerns around Sam and his wellbeing to be shared confidentially between GP and school.