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'Services failed to meet Samuel’s unique needs'. Week 1 Inquest Reflections

The first week of Samuel's inquest is over. A small milestone. All health and social care witnesses have now delivered their evidence.

These five days have blown my mind, and left me catatonic each evening. I'm unable to process the enormity of the evidence in the moment. I travel back to my Air B&B in a daze, stunned by the day’s events.

I watched the jury being sworn in on day 1, knowing they were going to hear and judge the innermost details of my child’s life. I looked on when the video we created to portray Samuel’s life was played. Five minutes to capture his unique character, talents and huge personality, plus the heartbreak of his loss. You could have heard a pin drop.

I gave my evidence on the first day. Stories of A&E visits; fears for his life and advocating for him at every turn. Describing the initial naïve approach and then the generic services that failed to meet his unique needs. I gave my everything as I was interrogated. My God, I hope I did him proud.

I've known most of the first witnesses. Many were a key part of Samuel’s life. They were good people, invested in his care and deeply impacted by his loss. Most cried when they gave evidence, choked up when they described Samuel’s cheeky style and big personality. His psychiatrist broke down when he gave condolences and said he thought about Samuel every day.

I hugged many of the witnesses in the courtroom and in corridors, after their evidence. I wanted to convey my thanks and understanding. Not only is this a gruelling process but they carry Samuel’s loss. The ripple effect of suicide loss cannot be underestimated.

The mental health Trust lawyer chose to read out many passages of Samuel’s medical notes. He described him having his hair cut, being excited about his music studio sessions and waiting for a takeaway to arrive. It thrust me back into a world where he was alive. Samuel was in the room, smiling and enjoying these simple things. I had ordered him that chicken and chips. I had to leave the court, unable to cope with hearing everyday details as part of legal point-scoring. I took deep breaths in the toilets to refocus, knowing I had to return, fearful of missing anything vital.

I listened to two social care workers use poor recollection as their defence. ‘It’s two and a half years ago’ they declared. I’m sitting feet away. Yes, I know it’s two and a half years, I’ve lived and breathed every moment of that time. It’s not too much to ask them to review their records and turn up to court prepared. They didn’t get my hugs.

I heard from the CAMHS crisis consultant. He defended not involving Samuel’s family in his care as he was 17 and a Looked After Child. The huge judgement that came with that comment hit every nerve in my body. I was livid. It’s not lost on me that my current NHS England CAMHS work is reviewing the crisis guidance on health inequalities. I would appreciate the irony if I weren’t so horrified.

I'm struck by the support I've received in the past week. People have reached out with heartfelt messages of kindness. I’m frequently surprised that support comes from unusual places. Strangers or people who know the heartache of child loss seem to pitch it right. They do not ask questions. They say they do not need replies. This makes me smile. They know texting messages is often beyond our capability

Home-cooked meals have arrived from family to help sustain us and they have sat in court, supporting us and Samuel. I know hearing the details of his final months must be shocking and traumatic.

Samuel’s story has appeared in the London press and I’ve shared it on social media. Seeing your child’s face staring back at you from newsstands and on TV takes the surreal to another level. We know reporting comes with its risk, but the wider issues are too important to hide away. Samuel was our precious boy and if we face judgement then so be it.

Next week we move into expert witnesses and then onto the two police incidents and respective forces. I will not know these witnesses. There will be no emotional connection. I hope for truth and integrity. Together with my 3 living children we will enter the courtroom, take deep breaths and advocate for Samuel and other vulnerable adolescents. We now stand as his voice and his legacy to enact change.


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