Family devastated after inquest reveals evidence of “multiple missed opportunities” to prevent son’s death

Leo Toze with his mother, the Revd Sharon Grenhan-Thompson

The mother of Wixams teenager Leo Toze has said that their family feels “re-traumatised” following the inquest into his death by suicide and that she will fight to see justice done for other young people.

Leo was 17 years old when he died after being struck by a train after intentionally making his way onto the tracks near Biggleswade railway station in September 2021.

His mother, Revd Sharon Grenhan-Thompson, the broadcaster and former prison chaplain at HMP Bedford, told the Bedford Independent that she felt “devastated and let down” hearing the evidence provided by Bedfordshire Police, East London NHS Foundation Trust’s (ELFT) and the Child and Adolescent Mental Health Service (CAMHS) staff.

Evidence of flawed processes by the police and mental health services was highlighted.

“There was blatant evidence of gaps in care Leo received,” said Sharon. The family now have to endure further trauma as the highlighted failings are brought to the attention of senior managers in each organisation for further investigation.

“Unless there is a formal intervention, we’re concerned that these failings will keep happening. Systems don’t change; the failings are still there and no one has accepted any responsibility.”

There has been no independent regulatory investigation or criticism by the coroner of any of the organisations that had contact with Leo prior to his death.

The coroner has, however, requested further evidence from the police and mental health trust regarding their response to vulnerable individuals. This will inform whether he goes on to make a Prevention of Future Deaths (PFD) report.

In addition, the coroner has written to the Culture Secretary and the Digital, Culture, Media and Sport Committee in respect of organisations such as Twitter being outside the reach of UK coroners courts.

This is because of being based in Europe so while that had no impact on this Inquest it may and is likely to in others.

Falling through the cracks

Before his tragic death, Leo’s family had made a series of frustrating and unsuccessful attempts to get professional support from mental health services.

Leo had a childhood diagnosis of Autistic Spectrum Disorder and from August 2020, he was under the care of the East London NHS Foundation Trust’s (ELFT) and the Child and Adolescent Mental Health Service (CAMHS) for depression.

He attempted suicide on two occasions in January 2021. He was prescribed an anti-depressant medication and in August 2021, the family say the dosage was increased from 10 to 20 mg without appropriate monitoring. Suicidal ideation is a known side effect of the medication prescribed and talking therapies proved ineffective for Leo.

On 31 August a friend called 999 in the early hours after seeing messages on social media that Leo intended to take his own life that day and had made a plan. His online friends reported their concerns to the police and said they had ‘info to help’ but this was never investigated.

There was no real or thorough investigation into the Twitter suicide plan by police, or by the Child and Adolescent Mental Health Services caring for him.

Two Bedfordshire Police officers attended Leo’s home for a welfare check where he was at home with his mother. The inquest heard evidence from the officers attending Leo that they were not made aware of the nature of the plans he had set out online and those with responsibility to investigate the matter had not done so.

As a result, they did not appreciate the seriousness of the suicide risk presented to them and could not inform Leo’s family about the increased suicide risk or respond appropriately by securing urgent medical care for Leo.

A safeguarding referral was made by the attending officers, but the crisis team did not receive the Safeguarding a Child referral at any stage. The referrals are not received by the Crisis Team but another department within the Local Authority.

On 31 August, Leo spoke to East London’s Crisis Team twice. Two days later, on the day before his death, Leo spoke to the team again but was assessed as low risk because they were not aware of the suicide plans he had made.

Sharon Grenham-Thompson (image: Don Weerasirie/Limelight TV)

Tragically, on 3 September 2021, Leo carried out his plan and was fatally struck by a train in Biggleswade.
“If information had been shared, different actions would have been taken,” said Sharon.

“The system is broken. 12 years of abysmal austerity and government underfunding and the system is falling apart.

“When we rang the crisis line there was no response. There is no adequate out-of-hours provision. It’s appalling.”

Missed opportunities

The inquest heard that the multi-agency mental health triage services do not provide out of hours cover for members of the public.

The system for the police and the East London Foundation Trust (ELFT) to communicate about vulnerable individuals including children, failed, as the Trust do not directly receive safeguarding referrals sent by the police.

The Coroner, Dr Séan Cummings, has called for more information from the police and ELFT about their information-sharing protocols, and about the mental health triage services provision so that he can consider whether to make any recommendations for improvement to prevent future deaths.

However, Sharon feels that justice has not been done.

“Leo’s treatment was cursory and shameful,” she said. “This was not adequate care for a teenager.

“People have not been held responsible and we are left bereft. We’re left with a narrative that now requires further investigation. I feel that responsibility effectively being placed onto Leo for what happened is shameful.”

“Vulnerable teenager let down by the system”

Leo was a much-loved son and brother with “a dry wit and clever sense of humour”. He was described as compassionate, tolerant, articulate, polite, generous and perceptive and was due to study maths at Warwick University.

The coroner’s findings stated: “Leo Toze died on the 3rd September 2021 by suicide. He had formulated a plan, which was not revealed to others, Leo reassuring police, clinicians and his family that while he had suicidal thoughts, he had no plan.”

Specialist solicitor Rhiannon Davies from Novum Law, who represents the family, said: “Leo was badly let down by the police and mental health services. He did not receive the emergency care he so desperately needed due to systemic failures to share information about vulnerable individuals.

“While nothing can make up for the tragic loss of Leo, it’s vital that the emergency services and the NHS take steps to improve their communications in order to properly protect and care for vulnerable people, particularly children.”

The family were supported by INQUEST, a charity providing expertise in deaths involving multi-agency failings. This includes work around the Hillsborough football disaster and the Grenfell Tower fire.

Jodie Anderson, Senior Caseworker at INQUEST, said: “Leo was a vulnerable teenager with autism and mental health needs. He needed specialist and sustained care and support.

“Those who were meant to keep him safe repeatedly dismissed concerns raised by his family and failed to take them seriously. His death is one of a series of concerning deaths involving children or young adults with autism.

“The lack of a multi-agency approach and many missed opportunities by multiple services point to the systemic failures that repeatedly fail children like Leo who die trying to access support. We need urgent change and investment in appropriate child-centred, autism-focused mental health support.”

In a statement to the Bedford Independent, a spokesperson for East London NHS Foundation Trust (ELFT) said: “The Trust extends its sincere condolences to the family of Leo Toze.

“Patient safety is our foremost priority. Following internal investigations a number of practice change recommendations have been implemented within the service. Working with system partners we are committed to developing additional system improvements as noted from the hearing.”

“This mother will fight”

Following Leo’s death, Sharon took part in a documentary that features Bedford families affected by mental health and suicide.

The producer of the film, Sophie Whelan, said: “I never got to meet Leo but I did get to hear the pain in his mother’s voice just a few months after he passed.

“The story she told is one that will never leave me. Leo was not provided with the specialist support he needed in such a vulnerable and difficult period of his life. It’s absolutely heartwrenching and I’ve heard far too many stories that echo these failings.”

The documentary, Me, Myself & Mental Health, is directed by Sophie and Don Weerasirie, produced by Bright Emotions and Limelight TV and edited by Jack Brown. It will be released later this year.

Following the conclusion of the inquest, Sharon has taken to social media to share her frustration, saying on Twitter, “This mother with fight.”

“I’m not lying down and accepting this is the end,” she told the Bedford Independent.

“I will use my platforms to continue to highlight the needs of young people and their families while I also try to put my life back together.

“These have been the darkest times of our lives, but the support and love our family has been shown means so much.”

Update: This article was updated on 20 November 2022 at 11:51am. We updated some elements in response to the family’s legal team. We have amended ‘police mental health triage’ to ‘multi-agency triage’ and included a comment from the Coroner’s report in response to the statement from the family’s solicitor. We are happy to make these changes.

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