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The mother of a "charming, loveable and intelligent" teen who took his own life has hit out at mental health services for not doing more to stop him.
It comes after a coroner said she would be writing to the NHS trust in charge in a bid to try and prevent future tragedies.
Ellis Murphy-Richards, 15, died after being hit by a train in West Minster, Sheppey, on September 30, shortly after walking out of a counselling session. Three men had intervened to try and bring him away from danger.
Concluding the inquest at Maidstone's Archbishop's Palace today, coroner Sonia Hayes, raised concerns about the care the transgender teenager received just hours before his death.
She explained how on September 29, the night before, the 15-year-old had tried to take his own life at his grandmother's house in Faversham.
Nan Sharon Murphy rescued him before relaying the incident to Dr Shobha Puttaswamaiah, a child and adolescent psychiatrist, during a phone call the next morning.
The doctor advised Ms Murphy and Ellis to continue with a scheduled appointment with April Tume, of the Children and Adolescent Mental Health Service (CAMHS) at Seashells children's centre in Sheerness, later that day at 3pm.
However, coroner Hayes explained Dr Puttaswamaiah had deviated from Ellis' safety plan of going to A&E if an event like this happened, as well as "not sharing fully the details" of the incident the previous night when speaking to Miss Tume over the phone.
Miss Tume heard what happened when she met with Ellis later that day and told him he should go to A&E, as per his safety plan.
The former pupil at Highsted Grammar in Sittingbourne and Oasis Academy in Sheppey refused to go.
After seeking advice from her manager Miss Tume was told she would need to call the police if Ellis still refused, however, he decided to walk out of the Rose Street site, leaving his phone behind so he couldn't be contacted.
The mental health worker tried to follow him out but couldn't catch up and was put in an "incredibly difficult" position, according to the coroner, before choosing to ring 999 and inform police she thought Ellis would take his own life.
At a previous hearing, speaking through tears, Miss Tume said she "just really, really cared" about Ellis. "I am very sorry that this has happened," she added.
The inquest heard how at around 4.40pm, just less than an hour after he left the Seashells site, Ellis died from his injuries.
At the end of the hearing Ms Hayes explained to the North East London Foundation Trust (NELFT), which runs the mental health service at Seashells, she would be writing a section 28 report.
It will cover how Miss Tume was left on her own to deal with events after raising concerns, as well no contingency plan being in place to deal with a young person who refuses help.
A section 28 report is written by the coroner to prevent future deaths, with the aim of improving public health and safety.
Concluding the inquest Ms Hayes ruled the teenager's death as a tragic suicide, before passing on her condolences to Ellis' mum, father, nan and uncle who attended the hearing virtually.
Ellis' tragic death came just weeks before his 16th birthday and the teen was described as "charming, loveable and intelligent".
It was heard he had a history of self harm and suicidal thoughts and was in hospital from February until June 16 last year, when he went to live with his nan in Faversham.
His mum Natasha Murphy, of Epps Road, Sittingbourne, had previously said her son was "articulate and musical", as well highlighting TikTok as a "serious factor" in his death.
In a statement following the hearing, she said she was "deeply saddened and angered" that Ellis's safety plan had not been amended to keep him safe in the event he refused to go to A&E.
She said: “I am disappointed that a short form conclusion was provided by the coroner.
"My hope and the promise, which I made to Ellis in the eulogy I read at his funeral, was to do whatever I can to make sure other young people get the support Ellis did not.
"I am pleased that a prevention for future deaths report will be written, although am fearful that the Trust will not change their policies to protect others or learn lessons from Ellis's death.
"I feel Ellis's death could have been prevented, like all suicides and was not inevitable.
'These clear issues must be addressed urgently, not only in Kent but nationally'
"I believe that had Ellis not have attended his CAMHS appointment at Seashells on the day he died, he would still be alive today.
"I believe CAMHS provides a one-size-fits all service rather than what should be person centred, as Ellis had said on many occasions that the clinical treatment was not helping him. I am shocked and disgusted to hear that Ellis having suicidal ideation of jumping from railways bridges was not in his risk assessment, despite over 19 entries in the CAMHS records of this.
"I plan to continue to campaign for justice for Ellis.”
Bola Awogboro, caseworker at Inquest, a charity which supports families through the inquest process, said: “It is shocking that a service caring for young people with complex mental health needs has no policy for responding to children in crisis.
"The mental health professionals who spoke to Ellis on the day of his death knew urgent interventions were required, yet their plans were reliant on A&E, the police, and Ellis’ family.
"His family were given little support, information, or options to help protect him. These clear issues must be addressed urgently, not only in Kent but nationally, to ensure other young people in crisis are protected and their families are supported.”
Clare Evans of Taylor Rose MW solicitors, who represents the family, said CAMHS' inadequate contingency planning and lack of a written policy for dealing with suicidal young people was "shocking" and represented "systematic failures".
Brid Johnson, Director of Operations, North East London NHS Foundation Trust (NELFT), responded to say: “We would like to express our deepest sympathies to the family and friends of Ellis Murphy-Richards.
“Our team had a long-term relationship with Ellis and delivered care based on their assessment of his presenting condition. Following the incident we conducted an investigation and reviewed our practices to ensure we continue to provide safe care.
“We will work with health and social care partners across Kent and Medway to review and improve the care and support we provide to our patients and their families.”
For confidential support on an emotional issue, call Samaritans on 116123 at any time or click here.
