Coroner highlights “Inadequate support” from council social services team in report on boy’s death

A boy who died falling from a cliff passed away due to high-risk behaviour, related to his Prader-Willi syndrome, on a background of "inadequate support" from his local authority, Kent County Council, a coroner has found.

In a report on the boy's death, Assistant Coroner, Catherine Wood, wrote that if the council had provided a package of care and a proper school placement at an earlier stage, the risks related to his behavioural issues may have been reduced.

The boy, named Samuel ("Sammy") Alban-Stanley, suffered from Prader-Willi syndrome, which is associated with behavioural problems. He had also been diagnosed as suffering from autistic spectrum disorder and anxiety.

As he got older, his behavioural problems increased, leading to episodes of extremely high-risk behaviours. He had made attempts to jump out of moving cars, building windows, had run into the sea in an attempt to drown himself, and had swallowed needles on at least two occasions.

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He and his family moved to Kent in 2018, but Samuel was without educational provision until March 2019, following an appeal against a decision for him to be in a mainstream school. At school, he benefitted from strategies put in place to deal with his high-risk behaviour when he became distressed. "Despite his challenges he was happy at school," the coroner reported.

The coroner said that it was "[o]f note" that the children with disabilities team at Kent County Council had chosen not to assess Samuel as they considered on paper that he did not meet their criteria.

"As a consequence Samuel was seen by social workers from the children's social work team who were unfamiliar with the range of services which could have been provided to a child with disabilities and their family," the coroner wrote.

Multiple attempts to involve the children with disabilities team were made beginning in May 2018 through to 2020, but all were unsuccessful.

The coroner said: "The failure to have specialist support or advice meant that Samuel and his family did not have access to a range of support which may ultimately have made a difference to his death.

"If a package of care had been implemented at an earlier stage, in conjunction with a school placement at an earlier stage, then the risks associated with his Prader-Willi episodes may have been reduced."

According to the coroner, Kent Social Services was aware that during an episode, Samuel was at high risk of harming himself and had undertaken life-threatening behaviour in the past.

In March 2020, five days before the introduction of the first UK lockdown in response to the Covid-19 pandemic, the family received a letter which stated that Samuel should shield as he was vulnerable to the virus due to his Prader-Willi syndrome.

His mother contacted social services, informing them that they would need more support at home. A month later, in a Child in Need meeting, a discussion about options was had, but no support was initiated to reduce the increased risks for Samuel of not being in school.

Two days after the meeting, the family called the police asking for support, and Samuel was heard to be shouting that he wanted to kill himself.

On 22 April 2020, Samuel woke early and appeared to go downstairs to make breakfast while the rest of the family went back to bed. He left the house and climbed over the railings on the upper promenade at Victoria Parade in Ramsgate.

He subsequently fell from the cliff shortly after 7 am. Despite receiving treatment, he passed away in hospital as a result of his injuries on 26 April 2020.

The coroner concluded that: "Samuel Alban-Stanley died as a consequence of injuries sustained during an episode of high-risk behaviour, related to his Prader-Willi syndrome, on a background of inadequate support from the Local Authority and Mental Health Services."

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."

Patricia Alban, Samuel’s mother, 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.”

She added: “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.”

Leigh Day solicitor Anna Moore who represented Patricia Alban, 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 [coroner's] findings and ensure that no family in its care has to go through the same trauma.”

Adam Carey