The inquest into the tragic passing of Alex Dews opened on June 8th 2023, following his passing in hospital on 18 July 2022, four days after he was found seriously injured in a country park.
Alex was born female and suffered with his gender from a young age. This resulted in mental health battles, including anxiety and self-harm.
An inquest heard that before his death he had told staff at his school, Outwood Academy Shafton, he wanted to kill himself.
Evidence was heard that Alexās mother, Anna Ford, would often get phone calls reporting that Alex had gone missing or had been hiding in the school toilets when he was supposed to be in lessons.
A referral to the mental health charity for school aged children, Ispace Wellbeing, was suggested to Alexās mother and agreed. However, the referral from the school was not made until 16 weeks later.
The inquest heard that Alex had self-harmed in school multiple times, which were not reported correctly in school records, social services were not contacted, and emergency services were never called.
Handwritten notes by Alex were found, including letters to school staff which clearly showed Alexās intentions to end his life. These letters were not given to his mother nor any medical service provider prior to Alexās suicide.
That same month, Alex tried ending his life by taking an overdose of Paracetamol, causing him to be sick. A suicide note was found by his mother in his bedroom.
The inquest heard Alex told his mother that a teacher at school had told him that the Crisis Team at the hospitals A&E department were ānot much helpā and the waiting times were long, so he didnāt feel comfortable going and didnāt seek help from medical professionals.
Following his suicide attempt, Alexās behaviour of going missing during school hours continued.
The inquest was adjourned until September 2023, due to Outward Academy failing to disclose salient paperwork. A second failure of disclose salient paperwork, result in Coroner Combes advising there would be potential repercussions of being held in contempt of Court if all disclosure was not made. The family state āThis is another example of how Alex is disregarded and is life seems unimportant to anyone except those who love himā.
Coroner Combes called for a review of the way mental health referrals are made by schools as there were “issues that need resolving”. She said she would be writing a prevention of future deaths report to organisations, including the Department of Health and Social Care, about her concerns over the way referrals are made to CAMHS, saying she had been left “slightly horrified” the school was left to make crucial decisions about which services to refer Alex to.
She said she also had concerns about the way schools and counselling services share information stating, “I can absolutely see that there are issues that need resolving.”
The family of Alex were pleased the PFD report had been requested. However, feel that the school showed lack of care and compassion for their beloved Alex, whilst he was alive and their conduct during the inquest was a further insult and lack of regard for their loved one.
The family state the love they had for Alex cannot be measured. Their hearts will be forever broken and a space that will never be filled.
The family state that they have little faith the school will put into place the changes they have said to have implemented, due to the disregard they had for Alex and feel the only way they can ensure others do not go through what they have gone through is to approach their Local MP for support.
To date, the CAMHS referral system has not been improved and the family have continued concerns that another child may lose their life, in similar circumstances to Alex.
The family were represented by Amy Fiddler of Howells Solicitors and Abigail Telford of Park Plowden Chambers.
Amy Fiddler said āHowells were approached by Alexās family in their time of need and in their own words āthey had lost all hope of finding helpā. We acted as swiftly as possible to ensure this devastated family had the representation they needed to help them through one of the most difficult journeys they had to face.
āA Regulation 28 ruling was made, which the family acknowledge may prevent another family suffering as they have, and a life may be saved in Alexās name.ā
Further Coverage of the Inquest:
BBC
Courts & Tribunals Judiciary