A Senior Coroner has found that an “underestimation” of suicide risk and significant mental health ‘failings’ contributed to the death of a vulnerable teenager.

Locket Williams, 15, described by their family as “a lovely person with a huge character”, tragically killed themself in September 2021.

Senior Coroner Richard Travers concluded there were a number of failures by Surrey and Borders Partnership (SABP) NHS Foundation Trust’s Children and Adolescent Mental Health Services (CAMHS). Contributing to the death of the vulnerable teenager, who went by they/them pronouns.

Locket’s older sister Emily said: “Hearing the coroner recognise what we have believed for three long years—that failures by CAMHS contributed to Locket’s death and ultimately meant Locket lost all hope—is heartbreaking.

“We’re thankful for the Coroner’s respect for Locket’s identity, which was so important to them, and we sincerely hope this process will help prevent more tragic deaths like Locket’s in the future.”

Locket had a long history of mental health difficulties, resulting in self-harming behaviours and three previous suicide attempts throughout and within seven months in 2021.

Evidence heard at the inquest highlighted “illogical conclusions” that Locket was deemed “low risk” by clinicians. Despite their ongoing suicidal ideation and three suicide attempts in close succession, the family’s lawyers said. 

Travers found that Locket’s high risk of suicide was “underestimated” by clinicians. There was an “insufficient account” of Locket’s long-running risk, which meant Locket did not receive the treatment they needed. 

The family’s solicitor Elle Gauld, from Simpson Millar’s public law team, said: “CAMHS’ approach repeatedly defied logic and palpable evidence of suicidality, bypassing the patient’s express wishes and placing an unrealistic burden on a family already in crisis.”

Long waiting lists for Cognitive Behavioural Therapy (CBT) and a shortage of therapists meant that, although clinicians all agreed CBT was necessary, Locket remained at home.

Travers said there was a ‘failure’ to assess the likelihood Locket could be kept safe while waiting eight months for CBT, a treatment they were ready and willing to engage in. 

Failures in communication between social services and CAMHS were also identified, leading to crucial information being missed in Locket’s assessment and care. CAMHS failed to attend Core Groups meetings held by social services to protect Locket.

Locket’s mother Hazel Williams, said: “We hope the lessons learned from their death highlight the urgent need for change and prevent future tragedies.

“We are grateful for the thoroughness of this inquest and the potential for positive changes in managing mental health services for young people.”

A SABP spokesperson said: “We are extremely saddened by the tragic death of Locket Williams and our deepest sympathies go to their family and friends. 

“We are carefully reflecting on the Coroner’s findings and the questions we have been asked and will respond within the given timeframe.”

SABP has 56 days to respond to the Traver’s findings and he has asked the NHS Trust to report whether there is a system now in place to ensure that young people are seen and treated promptly at CAMHS.