SOLOMON JAMES BEALEY · Prevention of Future Deaths report

On 5 February 2015, I commenced an investigation into the death of SOLOMON JAMES BEALEY, AGE 15 YEARS. The investigation concluded at the end of the inquest on 30 September 2015. The conclusion of the inquest was Medical Cause of Death: 1a) Self Asphyxiation; Conclusion: Suicide.

Solomon had some previous contact with Mental Health Services. In 2010 Solomon attempted to hang himself. Solomon's contact with Children's Services ceased in 2012. He presented with some problems with school work and he indicated on one occasion he was drinking alcohol. Solomon was self-harming and posting photographs of himself with a noose on the internet which was not known to parents or teachers. Solomon was found in his bedroom with a bag over his head and a cord round his neck on the morning of 5 February 2015. He left a note to all his family telling them he loved them and thanking them.

(1) Solomon was taken to see a Nurse at the Walk In Clinic on 1 October 2014 for minor medical matters. The Nurse became concerned at signs of stress and was aware that in 2010 Solomon was found preparing to hang himself, and so arranged for an on call Doctor to see him. No action was taken. The Nurse expressed her concerns to a GP in the practice. A telephone call was made to a number believed to be that of the mother of Solomon, but it was a wrong number. The Doctor wrote to Solomon's mother on two occasions and received no reply. The matter was not pursued any further.

(2) Although the letters had been received by Solomon's mother who discussed this with Solomon and his father and it was decided to take no further action, the Doctor was unaware that the letters had been received.
(3) No follow up action was taken.