A failure in care from Kent County Council and mental health services contributed to the death of a kind, gentle and creative 13-year-old from Ramsgate.
Sammy Alban-Stanley fell from cliffs at Ramsgate on April 22, 2020, after climbing over the railings. Emergency services were called and he was flown to King’s College Hospital but he died of his injuries four days later.
Sammy was autistic and lived with Prader Willi Syndrome (PWS), a rare genetic condition that causes physical symptoms, learning difficulties and behavioural problems.
For Sammy this included high risk behaviour that would result in self-harm and previous life risk incidents.
At an inquest held in Maidstone assistant coroner Catherine Wood said there was a clear failure in what was provided by Kent County Council to Sammy’s family to help with his care. There was a failure by the social services team to recognise an increased risk to Sammy and “it was possible if not probable that a failure to provide extra support contributed to Sammy’s death”.
The Coroner noted that the Children with Disabilities (CWD) team at KCC had chosen not to assess Sammy as it considered on paper that he did not meet the criteria for their support. As a consequence Sammy was seen by social workers unfamiliar with the services that could have been provided.
The coroner was also critical of the mental health service at North East London Foundation Trust (NELFT), saying that had information been shared in timely manner it is possible that more support could have been offered to Sammy and his family which may ultimately have made a difference to his high-risk episodes and his death.
Sammy’s mother Patricia Alban told the inquest her son was a kind, gentle and creative boy who enjoyed several hobbies, including piano, carpentry, upholstery and horse-riding. He was well known and popular in the Ramsgate community.
His family had done their utmost to support him to have a happy, fulfilled and healthy life. Despite all their efforts he died on 26 April, 2020.
The tragic fall happened during a time when, despite being one of the vulnerable children who could have continued to attend school during lockdown, Sammy had been required to stay at home to shield from COVID-19 because of the health risks caused by his PWS.
Sammy’s mum said the break in routine caused by the halt to school attendance, and the absence of any additional support, had been increasingly destabilising for her son.
Patricia said: “Sammy was exceptional, a dearly loved son and brother. With his wonderful sense of humour and happy disposition, we enjoyed a joyful family life. We had projects, adventures and a future planned. He had so much yet to give.
“Sammy bravely faced what society threw at him, persevering to try to overcome challenges arising from his disability. We had a very close connection and bond. I learnt so much from him, and I am so proud of him.
“Although I did all I could to cope with Sammy’s episodes, we were in crisis and the very limited support that we were finally awarded simply was not sufficient.
“We were operating at crisis point continually and things continued to escalate after Sammy was unable to attend school during the national lockdown. Every incident that Sammy had was life threatening and it was only my attempts to try to keep him safe, using all my energy and reserves, that nothing more serious happened before the 22 April. The authorities were aware of the risks but, in my view, did not take this seriously.
“I truly believe that a failure to provide us with adequate support led to Sammy’s death. The Coroner has heard evidence of all I did to fight to get the bare minimum in place to keep Sammy safe and yet this was always rejected. I was always told the support I desperately needed for Sammy wasn’t available and I should ask elsewhere. Nobody was willing to help us.
“Not only do I have to endure his loss but also the loss of his future too. Whilst he had a great many struggles due to his disability fitting into this world, his soul was gentle and resonated the deepest, most resounding love I have ever known. He brought joy and comfort to all who knew him, changed people’s lives for the better, he made my life multi-dimensional and multi-coloured. He made the world a much nicer place.”
Patricia had struggled over several months and years to secure out-of-school support for her son.
She said neither Kent County Council (KCC), nor the mental health service, North East London Foundation Trust (NELFT), was willing to offer any effective ongoing support, despite recognising that Sammy was in desperate need of this and his family were at crisis point.
The only option left to Patricia for help with Sammy’s behavioural episodes, as detailed in Sammy’s Crisis Care Plan, was to call the police. They would attend to help contain and calm Sammy which on occasion required him to be handcuffed or taken to a place of safety until he had recovered.
There were over 29 police contacts and at least 13 referrals made by the police to KCC. On two occasions Sammy was twice detained under Section 136 of the Mental Health Act due to the high risk he posed to himself.
His school, Laleham Gap, was a place where Sammy felt secure and well supported. The inquest heard evidence from the school’s Head of Wellbeing, that they were well-placed to support Sammy, in part due to the large numbers of staff available to provide him with one-to-one care if needed or to help keep him safe during an episode.
Despite their expertise, there were still a number of incidents at school, such as Sammy swallowing needles, which required him to be referred to hospital for emergency treatment. The inquest heard how school staff were very concerned about the impossibility of Patricia being able to keep Sammy safe on her own.
The school told social services several times that they had concerns for Sammy’s care and felt there was not enough practical support at home to manage the episodes. Even though Patricia was doing all she could, she could not manage without more support. Both the local authority and mental health services were aware that Sammy’s behaviour was incredibly risky and presented a threat to his life.
However, over a number of years Patricia said she had met a wall of resistance in her efforts to secure help in caring for Sammy at home.
The family had relocated to Kent in February 2018. There the Children With Disabilities (CWD) team had not become involved with Sammy’s case, saying he did not meet their criteria, the Children and Adolescent Mental Health Team (CAMHS) only offered medication and in August 2018 assessed him as having a “low risk of any self-harm or suicide” as the family acted as a protective factor.
KCC did not give Sammy an Education and Health Care Plan (EHCP), saying that he should go to a mainstream school, and one was only secured after Patricia took the matter to tribunal, after which Sammy was eventually given his place at Laleham Gap after being out of school for over a year.
In March 2019 the CWD team again rejected a request for support. In June 2019 the KCC panel denied a social worker’s request for direct payments for three hours help a day before and after school.
In July 2019 Patricia’s GP wrote to social services to ask for support as Patricia was “at breaking point”. That month the family was finally awarded funding for a carer to work 10 hours a week. The payments were not actioned by KCC until January 2020..
On 31 January Sammy was seen by a professor who wrote to social services stating that Sammy’s condition was life-threatening.
On 21 February 2020 at a CAMHS meeting, for the first time it was suggested that Care, Education and Treatment Review (CETR) could be actioned. Patricia said she was surprised it had not been mentioned before. This process was not actioned before Sammy died.
Just before lockdown, in March 2020, Patricia was made aware that Sammy’s case had been referred to an expert in rare diseases, whose expertise was known to the CWD team.
She questioned why the referral had not been made before the family’s situation reached crisis point. Patricia said she believed an earlier referral could have saved Sammy’s life.
The coroner gave a narrative verdict, saying Sammy died as a consequence of injuries suffered during an episode of high-risk behaviour related to PWS on a background of inadequate support from the local authority and mental health services.
‘Family in crisis’
Leigh Day solicitor Anna Moore represented Patricia. She said:“All the witnesses who gave evidence at the inquest rightly recognised just how devoted Patricia was to Sammy and yet her unfailing dedication to him and requests for support were repeatedly refused, mismanaged or delayed.
“She was met with a brick wall wherever she turned and the state bodies responsible for safeguarding and supporting Sammy failed to grasp the impact that Sammy’s disability had on his safety and just how hard it was for his family to manage alone.
“Patricia explored every avenue she could for help but was always told to go elsewhere. No one was willing to step up to provide proper support to this family in crisis. It was always somebody else’s problem.
“Patricia did all she could to provide Sammy with a loving home and supportive family unit. She could not have done any more. It is completely unacceptable that her requests for adequate support to keep her son safe were refused at every turn, leading to this incredibly tragic but sadly predictable outcome.
“I hope the local authority and mental health services reflect on the findings and ensure that no family in its care has to go through the same trauma.”
Selen Cavcav, senior caseworker at the inquest, said: “The findings of this inquest should shake the mental health and social care agencies to the core. Time for platitude about lessons learnt is over. A thirteen year old child died a preventable death. He could have been saved if the agencies talked to each other and listened to the family, or to Sammy who pleaded with them for help.
“There needs to be a complete culture shift and re-injection of the word “care” in our care systems, which time and time again avoids responsibility by hiding behind strict criteria’s and definitions.”
Matt Dunkley, Kent County Council (KCC) Corporate Director of Children, Young People and Education said: “The death of any young person is an unthinkable tragedy, and our thoughts and sympathies are with the family at this time for their heart-breaking loss.
“We wholly accept the coroner’s findings in this case and we are grateful for her acknowledgment of our reflective analysis outlining the valuable lessons learned and subsequent interventions and improvements put in place within our Children’s Services.
“We take our responsibility for Kent’s children extremely seriously and will continue to strive to deliver the very best care and support possible for them and their families.”
A statement from NELFT says: “We wish to offer our deepest sympathies and condolences to Master Alban-Stanley’s family and friends at this very difficult time.
“The Trust has taken a number of actions to improve its services following the sad death of Master Alban-Stanley, which was acknowledged by HM Coroner. The Trust are continuously reviewing the quality of care and treatment provided to patients and as an organisation we will reflect on the findings with a view to improving patient care in the future.”
‘Crisis in care for children’
County Councillor Karen Constantine, who represents Ramsgate at the authority, said: “My deepest condolences and sympathies go to the family for their terrible loss. The way in which Sammy and his family have been let down, and the way he and his family have suffered is beyond words.
“That so many of the professional services repeatedly let Sammy and his family down should be a wake up call and much more needs to be done. We need to fully understand what went wrong for Sammy and to learn those lessons. KCC and social services need now to reflect and to identify a ‘fail safe’ process, so that this can never happen again. We have a crisis in care for children in Thanet. Thanet has long been short of services for parents and far too many children have to struggle with a whole variety of unmet need, illnesses and difficulties.
“It’s time for KCC to recognise that there needs to be serious attention given to every request for help. I agree with the conclusion of the lawyers Leigh Day, that every decision needs to be assessed robustly and that we need a ‘culture shift’ so each and every case raised is met with care.
The Prader-Willi Syndrome Association UK (PWSA UK) provides information and support for people whose lives are affected by the syndrome. You can call the PWSA helpline on 01332 365676.