Inquest into the Death of Alex Dews Highlights Serious Safeguarding Failures

Howells Solicitors represented the family of Alex Dews at an inquest that exposed critical failings in school safeguarding and delays in mental health referrals, resulting in a Prevention of Future Deaths (PFD) report.

Overview of the Inquest

Howells Solicitors acted on behalf of the family of Alex Dews at an inquest examining the circumstances surrounding his tragic death.

The inquest opened on 8 June 2023, following Alex’s death in hospital on 18 July 2022, four days after he was found seriously injured in a country park.

This case raised significant concerns about safeguarding procedures, mental health referrals, and the responsibility of schools in protecting vulnerable young people.

Background and Mental Health Concerns

Alex had experienced gender-related distress from a young age, contributing to ongoing mental health difficulties, including anxiety and self-harm.

In the months leading up to his death, Alex raised concerns about his wellbeing with staff at Outwood Academy Shafton. Evidence presented at the inquest confirmed:

– Repeated reports of Alex going missing during school hours

– Incidents where he was found hiding instead of attending lessons

– Ongoing communication between the school and his mother regarding his welfare

Despite these warning signs, appropriate safeguarding measures were not implemented.

Delays in Mental Health Referrals

The inquest heard that a referral to a specialist mental health charity, Ispace Wellbeing, had been agreed. However, this referral was not made until approximately 16 weeks later.

This delay in accessing mental health support was a key issue examined by the Coroner, highlighting concerns around how schools manage referrals to specialist services.

Failure to Record and Escalate Safeguarding Concerns

Evidence presented during the inquest revealed multiple failures in safeguarding procedures, including:

– Self-harm incidents at school not being properly recorded

– No evidence of referrals to social services

– Emergency services not being contacted when required

– Failure to share critical information with Alex’s family or healthcare professionals

Handwritten notes and letters from Alex expressing distress and suicidal intent were discovered, yet were not passed on to his mother or medical professionals prior to his death.

Support for Families Facing an Inquest

Inquests can be complex and emotionally overwhelming, particularly where concerns exist around the involvement of public bodies or failures in care.

Families do not have to face this process alone. Specialist legal support can help ensure that the right questions are asked and that all relevant issues are properly explored.

Failure to Record and Escalate Safeguarding Concerns

Evidence presented during the inquest revealed multiple failures in safeguarding procedures, including:

– Self-harm incidents at school not being properly recorded

– No evidence of referrals to social services

– Emergency services not being contacted when required

– Failure to share critical information with Alex’s family or healthcare professionals

Handwritten notes and letters from Alex expressing distress and suicidal intent were discovered, yet were not passed on to his mother or medical professionals prior to his death.

Missed Opportunities to Intervene

The inquest also heard that:

– Alex had attempted to take his own life following an overdose of paracetamol

– A suicide note had been found by his mother

– Concerns were not escalated appropriately after this incident

Further evidence suggested Alex was discouraged from attending A&E after being told the Crisis Team was “not much help” and had long waiting times. As a result, he did not seek urgent medical support.

These missed opportunities to intervene were central to the Coroner’s findings.

Coroner’s Findings and Prevention of Future Deaths Report

The Coroner identified multiple failings in the care and support provided to Alex.

The inquest was adjourned until September 2023 due to failures by the school to disclose key documents. A further delay in disclosure led Assistant Coroner Abigail Combes to warn of potential contempt of court.

The Coroner raised serious concerns about:

– Delays in mental health referrals

– The role of schools in making critical safeguarding decisions

– Failures in information-sharing between agencies

She confirmed that a Regulation 28 Prevention of Future Deaths (PFD) report would be issued to relevant organisations, including the Department of Health and Social Care.

The Coroner noted she was “slightly horrified” that schools were responsible for making decisions about referrals to specialist services such as CAMHS.

Family Response Following the Inquest

Alex’s family welcomed the issuing of the PFD report and hope it will lead to meaningful changes in safeguarding practices.

However, they expressed deep concern about the lack of care provided during Alex’s life and the conduct of the school throughout the inquest process.

They continue to seek accountability and reform, working with their local MP to ensure lessons are learned to prevent similar tragedies in the future.

Legal Representation at the Inquest

The family were represented by Howells Solicitors’ specialist inquest team, alongside Abigail Telford of Parklane Plowden Chambers.

Howells Solicitors commented: “We were instructed by Alex’s family at a time when they felt they had lost hope. It was vital to ensure they had the legal representation needed to navigate a complex and distressing inquest process.”

“The Prevention of Future Deaths report is an important outcome and highlights the need for systemic change to protect vulnerable individuals.”

Support for Families Facing an Inquest

Inquests can be complex and emotionally challenging, particularly where there are concerns about failures by public bodies, healthcare providers, or other organisations.

Specialist inquest solicitors can support families by:

– Ensuring all relevant evidence is properly examined

– Raising key questions about failings in care

– Representing families throughout the Coroner’s Court process

If an Inquest Has Been Opened

If an inquest has been opened you can contact Howells Solicitors for independent and free case review, where will advise you on the best next steps for your family.

If possible, we may explore funding options and apply for legal aid if your case meets the qualifying criteria.

Learn more about our Inquest team. 

Our Inquest Solicitor are led by the well-respected Michelle Gyte and team includes senior legal expert Phillipa Matthews and solicitor Jenna Kisala and Elizabeth Walton who regularly act for families at complex and Article 2 inquests. The team forms a specialist practice group that strongly believes everyone deserves access to justice.

We assist families across England and Wales, including those attending Coroner’s Courts in South Yorkshire and the surrounding regions.

Contact us on  0114 2496611 and one of our advisors will be in touch to discuss your situation.

Further Coverage of the Inquest:

BBC

Courts & Tribunals Judiciary