TDoR 2022 / 2022 / May / 13 / Max Sumner

Max Sumner

Age 17

13 May 2022
Preston, Lancashire (United Kingdom)

Max Sumner
Max Sumner [photo:]

Max died by suicide. An inquest concluded that the care he received from Child and Adolescent Mental Health Service (CAMHS) contributed to his death.

A health trust has accepted the findings that it made major failings in its care of a transgender teenager who died by suicide.

Max Sumner, 17, died on May 13, 2022, while under the care of Lancashire and South Cumbria NHS Foundation Trust (LSCft) Child and Adolescent Mental Health Service (CAMHS). An inquest, which concluded on Tuesday, January 23, concluded the care he received was a contributing factor to his death, and LSCft has accepted the findings.

Max, from New Longton, told his father aged 16 he wanted to be known as Max and by male pronouns, and was a proud LGBTQ+ campaigner who loved drama and performing.

From the age of 15, Max had struggles with his mental health, including self-harm and attempts to take his own life. The inquest heard he had told mental health staff he was in “extreme emotional pain” and regularly told CAMHS and Childline he was thinking about suicide.

Childline breached his confidentiality three times in November 2021 due to imminent concerns about his safety, and referred him again to CAMHS in March 2022. However, none of these actions led to a mental health assessment or referral to social care.

A serious incident investigation by LSCft found Max should have been seen as a child in need of protection in November 2021.

Max’s final two contacts with his case manager were entered into the digital system after Max had sent a suicide note by email on May 13, 2022, but only seen the day after due to the case manager being on annual leave.

Despite regular emails from Max, these were not forwarded on while the case manager was on leave, and there was no contingency plan for a co-worker to support Max during periods of annual leave. Max did not want his family to know of his struggles, and CAMHS had not told his parents about the extent of his issues.

In total, Coroner Kate Bisset endorsed 13 failings by the CAMHS in Max’s care, which were:

  • Clinical and managerial supervision was not facilitated;

  • Safeguarding supervision was not utilised;

  • Non-compliance with safeguarding and clinical risk training;

  • No evidence of a multi-agency safeguarding plan;

  • No children’s social care referral;

  • Missed opportunities to discuss Max at a multi-disciplinary team meeting;

  • No evidence of care planning or safety planning;

  • Risk assessment not reviewed;

  • Emails from Max were not shared;

  • Max’s family were not involved;

  • No formal diagnosis was pursued and Max had no care or treatment pathway;

  • There was no follow up of his ADHD assessment;

  • No evidence of multi-agency working.

  • The Coroner found Max’s CAMHS case manager “kept Max to himself”.

“He did not share Max’s presentation, he did not escalate concerns and he did not involve higher chains of command.

“This meant that he was the only person with the whole picture of Max’s needs and any judgement calls about how to keep him safe landed on him alone, a situation which should not happen and should not have been allowed to happen.

“The responsibility for that does not lie with [the case manager] alone.

“Supervision should have been sufficient to understand that a highly complex young person, who [case manager] saw frequently was not on the radar to any other staff member.”

The coroner added: “I conclude had Max’s care been different, in particular had his confidentiality been breached in March 2022, along with escalation to children’s services and discussion of inpatient treatment, it is more likely than not that Max would not have died at the time at which he did because he would not have been afforded the physical opportunity.

“I am not able to say what would have happened to Max if his care was different. He may or may not have been admitted as a voluntary or involuntary patient.

“He may or may not have received a diagnosis and if he did, that may or may not have resulted in some comfort or stabilisation for Max.

“His mental health needs were complex and may have gone on to be enduring. But I am satisfied it is more likely than not that Max’s care contributed to his death.

“Max Sumner was a much-loved son, brother, nephew and friend. He was and remains truly loved. His death is an appalling tragedy for which I offer my sincere condolences to his friends and family. “

The Coroner recorded Max’s sex as male, which is thought to be the first time this has happened for a trans teenager.

Report added: 3 Feb 2024. Last updated: 10 Apr 2024

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