Better communication between NHS professionals could've helped 'troubled' Chorley teen, coroner concludes

Samuel Prince, 17, of Shaw Green Crescent, Euxton, near Chorley, died in April 2024 from drug toxicity.

He was found dead in bed at his father's home in Collingwood Road, Chorley.

Recording a narrative conclusion at Preston Coroners Court, assistant coroner Richard Taylor said he could not be sure what was in Sam's mind when he took the overdose.

The teenager was described as "vulnerable", with suicidal thoughts. He had been diagnosed with ADHD and was also suspected of having autism.

The inquest heard that Sam was found dead at his father's home after a night out. There was evidence of drug use in his bedroom, including morphine and other drugs.

There were no suspicious circumstances.

Sam was under the care of a specialist mental health team and had asked for a new case manager.

No-one was appointed for six months and his family said he felt "abandoned".

Join our new WhatsApp Community to get the latest news and top stories from across Lancashire directly to your phone

But NHS staff told the hearing that there was contact between them and Sam during that time, although not face to face with his usual professional.

Psychiatrist Dr Susanne Marwedel told the hearing that Sam "felt like he didn't fit in".

She said it would have been better if he had been tested and diagnosed with autism - which was suspected - rather than having to face a lengthy wait.

She said it would have helped Sam to have had the diagnosis as autism was a major contributor to the risk of someone harming themselves.

Dr Marwedel said a diagnosis would have helped Sam feel like he belonged to a community as he did not know why he felt different.

Sam's family voiced concerns during the two-day hearing and said there was poor communication between NHS staff and themselves, and different agencies.

They asked why a psychologist had not told them of Sam's "suicide plan" and said his perceived "discharge" from his mental health team had left him feeling isolated.

Coroner Mr Taylor said he hoped Sam's family had received answers to most, if not all, of their questions.

He said: "If autism had been diagnosed that would have been of enormous assistance to Sam to have that diagnosis and know that he wasn't alone."

Mr Taylor said Sam's "discharge" from the mental health team had been poorly handled.

"Better sharing of information could have and would have helped,” he added.

The hearing was told that steps were already under way to make sure that all relevant information relating to patients and risks were shared by mental health professionals.

Get the latest headlines, straight to your inbox, with The LEP’s free emails

Turning to the drugs overdose, Mr Taylor said Sam took some tablets first and the morphine would prove fatal.

"My belief is that he was beyond any rational thought at the time he was taking the morphine. I cannot say whether under the influence of that medication he decided he was going to end his own life."

The inquest was told at an earlier hearing that Sam had been a pupil at St Michael’s C of E High School in Chorley until the start of Year 10 in September 2021.

School safeguarding lead John Kirkpatrick told the court that there had been “incidents” at this time, after which Sam had moved to Shaftesbury High School in Chorley, a facility for children who have been permanently excluded from school or needed additional help for medical needs.

Sam was on a medical placement.

His mother and stepfather said they believed Sam was “groomed” into drug use by other pupils there.

They told the inquest that Sam was "crying out for help" from mental health services before his death.