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The mum of a transgender teen who took his own life has hit out at a "dismissive" mental health service, a year on from his tragic death.
Ellis Murphy-Richards died on September 30 last year after being hit by a train in West Minster, Sheppey, shortly after walking out of a counselling session at Seashells in Sheerness.
Following an inquest into the 15-year-old's tragic death coroner Sonia Hayes wrote to the North East London NHS Foundation Trust (NEFLT), which runs the mental health services at Seashells, in an effort to prevent similar deaths in the future.
The former pupil at Highsted Grammar in Sittingbourne and Oasis Academy in Sheppey had previously suffered with his mental health and previously tried to take his life.
The coroner highlighted ongoing concerns that, for children under the care of Children and Adolescent Mental Health Service (CAHMS), there is no protocol or policy for those that require Mental Health Act assessment and will not voluntarily attend A&E.
Ms Hayes's report also noted there was no contingency for these circumstances in Ellis’ safety plan, despite his history of suicide attempts and knowledge he had tried to take his life the night before he died.
On the morning of his death, the coroner also found the trust's psychiatrist deviated from the agreed safety plan, without an update to the risk assessment for his later appointment at 3pm with his care coordinator.
Nobody in the centre was able to complete a formal Mental Health Act Assessment or authorise detention and Ellis’ care coordinator was therefore given advice from management to call the police if he would not go to hospital.
The coroner found this advice did not account for Ellis’ history of absconding, or the fact that there was no contingency for staff to prevent him from leaving, as he did, after stating he would end his life.
In a response sent back to the coroner in August, NELFT's chief executive defended the trust's actions .
He said the trust "considers that it did comply with its safety plan for Ellis" and that despite police not being called until after Ellis had left, it believes it "acted within their remit as prescribed by law" as it had "no legal power to hold Ellis".
The chief executive continued: "As a learning organisation the trust fully accepts that there are always elements of cases that can be used for learning it will continue to reflect on its practice and procedures for all cases going forward."
Ellis' mother, Natasha Murphy, has now slammed the trust for making no commitment to changing or developing practices to protect children in the future.
The Epps Road, Sittingbourne, resident said: “One year on, I am angered that the trust does not seem to have learnt any lessons from what happened to Ellis, despite the coroner identifying the need for a report to prevent future deaths. I am deeply concerned that without local and national action there is a continued risk to other children.
"On the day he died, Ellis did not want to go to hospital. He made this clear but, despite Ellis stating he was going to end his life to his care coordinator, other options were not explored.
"There was a five hour window for CAMHS to intervene after the psychiatrist was made aware, on the morning of his death, that Ellis had made a serious attempt to take his life the night before. Yet no contingency planning took place, despite his increased risk.
"It is a sad truth that those with suicidal ideation cannot always ask for or accept help. It is clear to me that children’s mental health services should accept responsibility for implementing safeguarding measures where children do not wish to comply, and a formal policy is needed to ensure this is possible.
'Denial and defensiveness from mental health trusts frustrates the opportunities inquests provide to create change...'
"Ellis was under the care of CAMHS for nearly two years. As a family the only advice we were given to safeguard him was to lock away sharps and go to A&E, not how to support or understand his mental health. I believe there is a one-size-fits-all service for children’s mental healthcare and safety planning, which is failing people like Ellis.”
During the inquest in June it was heard how Ellis left the Seashells centre at around 3.40pm, about an hour after his appointment, and died almost an hour later.
He was hit by a train in West Minster, despite the efforts of a group of men to help him.
Ellis, who has been described as a "charming, loveable and intelligent" teen, was just weeks away from his 16th birthday.
Lucy McKay, spokesman for INQUEST charity, said: “Coroners do not issue reports to prevent future deaths lightly. These reports are intended to inform practice and improve policies, so lives can be better protected. It is shocking therefore that NEFLT Trust have responded dismissively to the coroner’s and family’s concerns.
"Denial and defensiveness from mental health trusts frustrates the opportunities inquests provide to create change. We hope the trust will reconsider their response, and that mental health leaders nationally will consider these ongoing issues with children’s mental health services.”
A spokesman for the NEFLT Trust said: “We would like to express our deepest sympathies to the family and friends of Ellis Murphy-Richards.
"We have met with Ellis' mother to discuss her concerns and we have worked with our teams to ensure the feedback has been reviewed.
"As a trust we are committed to delivering safe care for all of our patients and we take the learning from incidents seriously, ensuring that we continually review our practices.
"We are working 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.