The heartbroken mum of a 13-year-old who died by suicide said she was “let down” by the professionals who should have helped her.

Ella Louise Murray passed away on November 15, 2023, at King’s College Hospital, in London, after struggling with her mental health.

A four-day inquest into her death was held last week at Oakwood House, in Maidstone, where area coroner Catherine Wood was told about the circumstances leading up to the day she died.

The court heard how the teenager was struggling with her mental health following the death of her friend and had previously self-harmed and attempted to end her own life.

Two days before she died, Ella’s mum Natalie James was called by her teachers at Highsted Grammar School asking that she take the Year 9 student to A&E as she had told staff “she wanted to kill herself”.

The court heard that the secondary school, in Highsted Road, Sittingbourne, provided the family with a high-risk form for the crisis team outlining their concerns.

Ella, of Alexandra Road, Sheerness, was seen at Medway Maritime Hospital and told paediatric nurse Sara Weaver she was hearing voices and would end her life if she went home.

Ms Weaver told the hearing she called the Child and Adolescent Mental Health Services (CAMHS) and relayed what was said. The team accepted the referral.

For confidential support on an emotional issue, call Samaritans on 116 123 at any time or visit www.samaritans.org.

The “fearless” and “competitive” rugby player for Aylesford RFC was then seen by mental health nurse Caroline Akapelwa who assessed Ella as “medium risk” and decided to discharge her from the hospital.

Concerns were raised by Mrs James’ legal representative Shaun Murphy on why she was sent home when she had told Ms Weaver she would die if she did so.

However, Ms Akapelwa said Ella did not have the intent to end her life during their assessment and had accepted intensive home treatment which showed she had “futuristic intentions”.

She added: “My decision on the day was based on what Ella was telling me. Ella did not say she wanted to end her life.

“There was not anything that would have warranted Ella to remain in the hospital on the day I saw her. The young person I saw and sent home was not someone who was going to end her life.”

During the proceedings, Ms Wood was told Ms Akapelwa had not seen the form provided by the school, however, when questioned she said it would not have changed her decision to discharge Ella.

Throughout the evidence, the court heard following her hospital visit Ella ran away from home and was stopped by a stranger who called the police.

The next day (November 14), Ella was seen by mental health nurse Zoe Giaretta as per the agreed home treatment plan.

Ms Giaretta did not give evidence in court, instead, her manager from the North East London NHS Foundation Trust (NELFT) who provides CAMHS in Kent, Wayne Bennett, addressed the hearing.

He said from the assessment notes, Ella had told Ms Giaretta she would “hurt herself or others” if she stayed at home, would “go to prison” and was feeling suicidal and hearing voices.

The court also heard the teenager had asked to be admitted to the hospital but Mr Bennett said she would not have met the criteria and treatment would have continued at home.

He added that she had futuristic thinking as she was looking to be sent to an alternative place.

After Ms Giaretta left, Ella attempted to end her life and was airlifted to King’s College Hospital, in London. She died the following day (November 15).

During the inquest, the court heard how Highsted Grammar School made eight referrals to Front Door, a service used to report safeguarding concerns, but claimed they were ignored.

Giving evidence, the then-deputy headteacher, Tanya Cornish said: “It was frustrating that the referrals we were making to external services asking for that help were not listened to.

“Looking back you always think about what more you could have done but Ella had access to everything we had at Highsted.

“We were all concerned about her mental health. She needed external support, she needed CAMHS, she needed professional intervention.”

The family also received support from Kent County Council (KCC) Early Help, which provides initial help for families, and referrals were made to Kent School Health, a team of school nurses and practitioners, for counselling sessions.

If you want to talk to someone confidentially, visit www.kent.gov.uk/social-care-and-health/health/release-the-pressure.

In July 2023, Highsted Grammar School made another Front Door call requesting support and the case was assigned to a senior practitioner at KCC’s social services, Gary Hickson.

He told the court he spoke with Mrs James and was assured that the family was planning to pay for additional counselling and Ella’s GP had referred her to CAMHS.

A decision was then taken to close the social services case as the team decided the family “did not require additional support” and the family was taking the “appropriate steps” to support Ella, Mr Hickson explained.

After taking a week to deliberate, Ms Wood delivered her findings to the court on Thursday (December 19).

In her findings of fact, the coroner said she found it “incredible” that a 13-year-old could tell a nurse she was going to harm herself and a risk assessment was not completed.

She added: “I simply cannot accept it is reasonable to leave her at home even with a plan to see her the following day. There was a clear failure here to keep Ella safe.

“This was a child crying out for help and I find she should have been risk-assessed. Had she been, she would have been high risk.”

Ms Wood added she found it “disconcerting” that Ella telling Ms Giaretta she wanted to go to prison was futuristic thinking, instead, she said it was the words of a “desperate child” asking for help.

She declared Ella should have been taken to a mental health bed and admitted to hospital or an urgent discussion should have been held with partner organisations to ensure Ella was in a safe place.

Ms Wood added: “She needed support and she simply did not get it.”

A spokesperson for NELFT said an inquiry had been completed following Ella’s death. They added: “We were deeply saddened by Ella’s tragic death. Our thoughts are with her family and loved ones at this difficult time.

“As a result of the internal investigation, we have made several changes to ensure that the voices of children are heard by all involved in their care.

“Internal procedures have been reviewed and updated to reflect this, including electronic record-keeping practices, the rollout of risk formulation training and a review of the multi-disciplinary team’s function in the provision of care and treatment for children and young people.

“In addition, there have been system-wide events held with senior representatives from health, social care, and other system partners to review and improve partnership working and closer collaboration between agencies across Kent and Medway.”

Ms Wood concluded that Ella died by suicide after being seen by mental health professionals who she told she would harm herself or others and said there was a “failure” to complete a risk assessment or to take steps to ensure her safety.

A Prevention of Future Deaths (PFD) report will be written.

Speaking to KentOnline following the inquest, Mrs James said Ella was “crying out for help” and had been “let down” by those she entrusted to help her.

The mother continued: “She would have helped anybody but when she needed help, she did not get it. She was just a job to them, a statistic, but she was our whole world.

“I do not want any more Ella’s or parents sat here but from what I have heard there will be more.

“Parents should always trust their instincts. If they think professionals are not making the right choices, they should speak up.”

Paying tribute, she added: “Ella was outwardly beautiful, but her real beauty was what lay within her. Ella was fiercely loyal and loving to her family.

“It was impossible to feel sad around Ells, she always knew the right thing to say, whether that was a quick remark with her wicked humour or a positive affirmation filled with love.

“Ella was the centrepiece to our family puzzle, her love and warmth shone through our household and filled our hearts, her loss is felt beyond anything words can express.

“The firecracker that had everything to live for and the world at her feet is, painfully, forever 13. Our world will always have a missing piece that will never be found again.”

Ella’s family and friends have set up a TikTok page, LifeWithoutElla, to help support others who may be struggling and to raise awareness around young people’s mental health.