On 16 May the Sheffield Coroners Court held the inquest into the death of 15 year Noah from Sheffield, who was found to have died from a fall from height. The Coroner concluded that Noah died as a result of suicide.

Noah’s family describe Noah as, ‘a wonderful funny, caring and empathetic young man. Whilst his time with us was short his impact was massive for those who knew him.

Assistant Coroner Angharad Davies heard how Noah’s mother had taken Noah to his GP following concerns from a friend on social media that he had made a detailed plan to take his own life. The GP was aware a plan had been made, but failed to communicate this on the CAMHS (Children and Adolescent Mental Health Services) referral form and the request was sent as routine, rather than urgent. The Coroner noted, ‘[Noah’s GP] explained that she was told that Noah was feeling suicidal and making a plan to act on these thoughts…[Noah’s GP] accepted that she had provided insufficient information to enable CAMHS to risk assess Noah’.

Unfortunately the result of this is that a routine referral results in an appointment in 18 weeks, whereas urgent is 2 weeks.

CAMHS reviewed the referral and rejected it on the basis that they did not have enough information to adequately assess the risk. CAMHS requested further information from the GP in writing. The family were not made aware the referral had been rejected.

Noah was reported missing on 1 August 2018 and was unfortunately found dead on 2 August 2018. The family extend their gratitude to South Yorkshire Police for their assistance in locating Noah and in supporting the family in a very traumatic time.

The coroner concluded that the Human Right, Article 2 – Right to Life was arguably breached in that there had been a failure to protect Noah, who was a vulnerable person, and that those agencies trusted to provide help to Noah ought to have known that there was a real and immediate risk to the person’s life by suicide.

The Coroner found that insufficient information was provided on the CAMHS referral form, specifically the word plan was crossed out. CAMHS accepted that had they been aware of the plan Noah would have been seen within 2 weeks on an urgent basis. CAMHS accepted that the process to obtain further information was not sufficiently robust enough and telephone contact with the GP should have been made. The Children’s Hospital Foundation Trust who facilitate CAMHS undertook their own internal investigation which found, ‘the current referral form does not capture the information required to process referrals without delay’ .

CAMHS have since changed processes and have adopted a duty team that will now call if further information is needed to be obtained to assess risk. CAMHS now has access to GP computerised records. CAMHS will make further changes and by 2020 will accept telephone referrals.

However, for now the referral form will still be used despite the Trust accepting that it does not capture enough information to process referrals without delay. Due to this, the coroner has made a prevention of further death report request of the Trust to ensure that the referral form is investigated and changes to the form are considered to prevent inadequate information being provided to CAMHS in future.

The Coroner commented on the pressure’s on GP’s in practice to try and ensure that through thorough investigation, future deaths such as Noah’s can be prevented.

The family are thankful that changes have been made, so far, and are still being made regarding the referral process and take some peace in knowing that further deaths may be prevented in future.

Noah was a vey proud LGBT+ activist and following Noah’s death, his family set up a fund through a local organisation called SAYiT  and have raised £10,000 for LGBT+ children in crisis or hardship regarding their mental health (The Noah Lomax fund for Counselling and Hardship).

Noah’s impact and loss is felt within his local community, his family said, ‘Whilst his time with us was short his impact was massive for those who knew him’.

Switalskis continue to support Noah’s family.

You should seek legal advice if you think that the death of a loved one may have been caused by medical error or mistake. The clinical negligence team at Switalskis can help you if the coroner decides to hold an inquest. Call us on 0800 138 0458 or email help@switalskis.com