Finn Hall, a 16-year-old teenager from Huddersfield, died a self-inflicted death at his home in Keighley in November 2022. Finn had been struggling with mental health issues for many years, but his family constantly felt that he did not receive enough support or information from the mental health services involved in his care to help him.

Finn had a history of mental health problems, which began at the age of 11. His family believed he attempted to take his own life at least nine times. Despite these challenges, Finn was known as a 'fun' and 'clever' individual who enjoyed helping others. He was also in the early stages of transitioning from female to male, having come out to his family earlier in the year.

Finn was under the care of the Child and Adolescent Mental Health Service (CAMHS) in Bradford, run by Bradford District Care NHS Trust.

An inquest was held over the week commencing 30 July 2024 to investigate the circumstances that led to Finn’s tragic death. The inquest was held before HM Coroner Angela Brocklehurst, who indicated she would consider if the circumstances leading to Finn’s death were due to a breach of his Human Rights Act Article 2 rights – the right to life.

Finn’s family stated they were not fully involved in his care decisions. They argued that Finn, given his condition and history, should have been provided with 24-hour hospital care. They questioned the mental health services’ decision that Finn had the capacity to consent to be responsible for his own care as a teenager with significant mental health issues.

Risk assessment notes showed a pattern of deteriorating psychological issues from August 2022. There was limited communication with social services to advise of the safety plan in place for Finn. His mother had been asked to provide supervision 24-hours of the day. She told CAMHS that was impossible for her with a teenager, and that her other children had specific disabilities that required significant care from her. Social service records show they were not informed of this need for 24/7 supervision so saw no need to offer Finn’s mother any additional support or resources.

The inquest revealed that Finn had been prescribed anti-depressants and medication to aid sleep after another suicide attempt in early 2022. Dr Elizabeth Green, psychiatrist, described Finn’s case as ‘complex’ but confirmed he certainly had a mental disorder.

In early November 2022, Finn disclosed to his CAMHS keyworker that he was actively planning to take his own life and had decided to do this after Christmas. The family has questioned whether this disclosure met the threshold for urgent hospital admission and whether a mental health specialist should have immediately assessed him. His CAMHS notes recorded that “there was time”, given it was then only November and Finn had indicated his plan was for “after Christmas”.

In the days before his death, with his mental health now significantly deteriorating, the family rang his keyworker, requesting that his plans to commit suicide after Christmas be discussed with him at his appointment the following day.

This voicemail was recorded but never listened to. Finn then failed to attend his appointment with CAMHS. The only effort made to contact him was a phone call to his mobile phone, despite his keyworker knowing the phone was not working.

Internal Investigation Findings

Following Finn’s death, Bradford District Care NHS Trust ran an internal investigation into the care offered to Finn.

The report found nine key areas of improvement and three main criticisms, including:  

• A failure to assess Finn in late November or escalate his care, despite his deteriorating mental health.
• Opportunities to improve the use of generic safety plans and implementation of robust systems to escalate care of patients experiencing crisis or increased risks.
• An absence of case supervision for Finn, specific staff training and enhanced support.

Evidence was heard from key CAMHS staff at the inquest, who stated that Finn’s case should have been escalated to a psychiatrist once he had disclosed he planned to commit suicide.

Th inquest also heard evidence from patient safety advisor for Bradford District Care NHS Foundation Trust, Christopher Hardy, who said that there should have been "an escalation of the care being provided" .

He had identified "a number of risk factors over weeks and months that didn’t result in escalation".

Adding, “Particularly from the 8 November onwards, but also in the weeks before that, there was an escalation in his risk presentation that was not reflected in his risk provision”.

Awaiting the verdict

Having heard from nine witnesses, including staff from CAMHS and social services, the inquest is now adjourned until 9 August 2024 when the Coroner will deliver her verdict.

Finn’s mother is very clear as to her position:

"CAMHS was supposed to be the professionals but all they did was tell me to stay with Finn 24-hours a day, but also give him privacy."

She added: "I was a single parent... how was I supposed to look after Finn 24-hours a day?"

Finn’s aunt Abi Ford told the Pink News:

“We’re all absolutely devastated and heartbroken. Finn’s life has been taken far too young,” she said.

“He was a really kind and caring person… He always liked to make people smile. He didn’t like people being sad around him,”

Conclusion

The families legal team, led by Senior Associate, Tamlin Bolton , await the Coroner’s verdict on Friday.

Speaking on behalf of the family following the outcome, Tamlin Bolton, said:

“ CAMHS have made a number of beneficial changes to their service following Finn’s death, for which the family are grateful. We do believe that more could be done to ensure the robust systems talked about in their own investigation are properly in place and their use expedited. Finn’s death has caused so much tragedy and loss, impacting such a wonderful family and all of us involved in representing them following Finn’s death, simply want to make sure this does not happen in another home to another teenager.“

Find out more about Switalskis expertise in supporting families through inquests on our dedicated service page .