‘We are changed forever by his death’: Croydon teenager failed by multiple agencies, inquiry finds

An inquiry into the death of a teenager has found he was failed by multiple agencies that were supposed to look after him.

Samuel Howes, from Purley, was killed after being struck by a train at South Croydon railway station on September 2, 2020 – just one month before his 18th birthday.

The South London Coroner’s Court inquest concluded yesterday finding a series of failures by various agencies, including police, mental health and social services, possibly contributed to his death by suicide.

Samuel’s mother, Suzanne Howes, said: “Losing Samuel has been a crushing heartbreak, traumatic beyond our comprehension. Every day and each new experience that we encounter as a family is impacted by his loss. We are changed forever by his death.

“Samuel needed and deserved to be safeguarded. He was spiralling, frequently in crisis and returned to self-harming. I along with many professionals feared for his life. He said he wouldn’t live to be 18.

“Measures should have been put in place to protect him and provide wrap-around care to manage his safety. Croydon Children’s Services, as his corporate parent, should have led this response.

“The Metropolitan Police and British Transport Police should hang their heads in shame. Samuel was crying out for help in custody and severely self-harming. Multiple police officers labelled him ‘attention seeking’. The culture of casual indifference and lack of accountability of both police forces is shocking.

“Samuel’s last cry for help went unanswered. He called an ambulance for the first ever time stating he was suicidal, hours before his death. A robust police missing person investigation should have been initiated. Instead, he was failed.

“The inquest and its long, chaotic build-up have been brutal and harrowing. Hearing evidence of Samuel’s pain, unanswered cries for help and the many missed opportunities to save him will haunt us forever.”

The youngest of four siblings, Samuel was a passionate football player and big fan of Crystal Palace FC, his family said Samuel was happiest when using his talents to write and perform music.

In the three years prior to his death, Samuel had been admitted to A&E over 40 times and had 178 contacts with the police.

The inquest heard evidence from two Croydon Social Care managers who both said Samuel was highlighted as a case of huge concern. One had flagged concerns on their first day in the job as they considered the risk was so high.

In her evidence, Samuel’s social worker said that the sight of his self-harm at their first meeting, months before his death, reduced her to tears.

After Samuel passed his Maths and English GCSEs with flying colours in 2019, he returned to college, but was excluded as the school was unable to cope with his needs.

On August 30, 2020, Samuel was arrested by British Transport Police and held in police custody whilst under the influence of alcohol. A BTP officer described Samuel banging his head repeatedly and self-harming so badly his clothes were confiscated.

Samuel was left naked on the cell floor. In his evidence the officer described this behaviour as ‘attention seeking’ and ‘fairly normal’.

Samuel was released from custody 20 hours later, with no mental health assessment or ongoing safeguarding referral having been completed.

In the evening on September 1, 2020, Samuel was recorded as a missing person by the Metropolitan Police after an incident at his accommodation.

Early the next morning, Samuel contacted the London Ambulance Service (LAS) from his friend’s house whilst crying and expressing suicidal thoughts. Police officers visited the address but did not find Samuel there.

Hours later, Samuel was killed by a train.

The inquest concluded that Samuel’s death by suicide was possibly contributed to by the inadequate response of mental health and or social care services, the failure to adequately share risk information and the steps taken by the Met while he was in custody.

Detective Superintendent Fi Martin, South Area Command Unit, said: “Following today’s outcome we will now take some time to carefully consider the findings of the jury and seek to learn any lessons as part of our ongoing commitment to improving the experience of those living with mental ill-health when they come into contact with police.

“Part of that work has seen us introduce a dedicated safeguarding team that provides support to custody officers across the Met by carrying out reviews of all vulnerable detainees while they are in custody. A new evidence-based risk assessment tool that considers a wider set of factors and takes a more holistic view of the individual to identify vulnerabilities has also been implemented.”

BTP’s Assistant Chief Constable Charlie Doyle said: “We have been open and transparent throughout the inquest process and we accept that the relevant safeguarding forms should have been completed and submitted by the officers who dealt with Samuel in custody on August 30, 2020.

“In this case, we know that the officers involved in Samuel’s care didn’t complete the safeguarding forms because they felt they didn’t have sufficient information to do so at the time – but we accept these should have been completed in a timely fashion with as much information as they had available to them in order form part of the multi-agency response.”

Pictured top: Samuel Howes died one month before his 18th birthday (Picture: INQUEST)