On 2 August 2013 I commenced an investigation into the death of Peter Stanley (aged
17). The investigation concluded at the end of the inquest on 22nd July 2014. The conclusion of the inquest was that Peter took his own life by hanging but that there had been a number of missed opportunities to assist him by way of mental health assessment and care over the preceding weeks, most particularly towards the end of his life. However, it could not be said on the balance of probabilities that Peter would have survived if any or all of the opportunities had been taken.

Peter Stanley, aged just 17, was found hanging in woodland on the outskirts of Sheffield on 2nd August 2013. There was a history of concern regarding Peter's mental health, his problems possibly originating from use of a so called 'legal high'. An assessment by an experienced community mental health nurse (CMHN) at the end of 2012 recognised that Peter could be developing a psychosis and he was offered a care-coordinator. Unfortunately Peter subsequently refused to engage. It was felt better that the service withdrew with an open invitation for Peter to re-engage when he was ready rather than 'harass' him and potentially spoil chances of later engagement. On the 10th April 2013 Peter presented himself to the local authority as 'homeless' because his parents could no longer cope with his behaviour. He was seen by a housing officer and social worker. Peter did not want to be 'looked after' (that is go into the care of the authority) and a bed was found at a suitable establishment ('Roundabout') to provide assessment and help with more immediate issues. On the 3rd May Peter saw his own GP complaining of an injury to his back from 'falling downstairs'. Although not disclosed at the time it is clear that Peter suffered this injury when attempting to hang himself on stairs at his mother's address. The significant nature of his injury suggests a violent episode and given his non-disclosure at the time it would be difficult to see this as anything other than a serious attempt on his life. On 14th July Peter committed a serious and violent episode of damage at Roundabout. He was barred from the premises and thus rendered homeless. Peter was arrested for the damage and seen in the detention area by a custody nurse, because he had been banging his head on the wall. He denied any history of mental health issues and said he was only banging his head to cause trouble. Because of his behaviour Peter was subject to constant supervision in the police cells. He also required full bodily restraint at one point. Peter appeared before the Magistrates from custody next day (15th July) and was made subject of a referral order to the Youth Justice Service. The Youth Justice team (YJT) were not made aware of the bizarre behaviour in custody and arrangements were simply made to see him a week later. Later that morning Peter (now homeless) attended at the local authority Housing Dept with his father, although was not in the room for much of the interview. A social worker from Children's Services (SWCS) was also present. Housing had little to offer because of the circumstances in which Peter was removed from Roundabout and as there was no supported bed provision available he was declared 'intentionally homeless'. This left Peter to continue within the responsibility of Children's Services. Peter made a disclosure during this interview about his suicide attempt on the stairs but not whilst his father was present. In fact never knew of the apparently serious attempt on the stairs whilst Peter was alive. There were continuing but unsuccessful efforts to find Peter more suitable accommodation than the Bed and Breakfast initially allocated. The SWCS apparently felt that the YJT would be the quickest route to a mental health assessment — but despite discussion about Peter the YJT were not given any information about the mental health history or needs and nothing was put in progress. Although the Children's Services record system clearly identified the CMHN's previous involvement, he was not contacted at any time before Peter's death

On 31st July a YJT substance misuse worker, saw Peter for a drug screen (not in relation to mental health). Peter told her of many thoughts about suicide, of his attempt on the stairs now four months before and of hearing voices. He said that he felt very low and was so distressed that he wanted to run into oncoming traffic or slice his own leg off. He felt that he had very little support from anyone and feared that he might be schizophrenic. This was taken seriously and a meaningful risk of self-harm was recognised although not seen as immediate. An appointment to see the YJT mental health worker (who was on leave) was made for a few days hence. The SWCS was contacted but there was little more provided. Further action was left with the YJT pending the mental health assessment the following week. The YJT determined to support Peter pending the assessment -- but were not really equipped to do so. No contact was attempted with Peter's father, nor any attempt to seek a medical view of the situation by telephoning Peter's GP. The following day (1st August) Peter did not attend a planned course. The YJT telephoned him twice. The first time he was plainly under the influence of drugs/alcohol and said he was unwell. When called later he was incoherent. The YJT became very worried and called the SWCS. Nothing seems to have come from this save that arrangements were made for an out of hours team to telephone Peter each morning over the coming weekend. Peter's whereabouts were unknown as he was not at the B&B. In fact, Peter was actually with his father that same afternoon. He described Peter as withdrawn, abrupt and intolerant. He plainly didn't see his son as suicidal but then he had no knowledge of either the earlier attempt or of the disclosures to the substance misuse worker. They parted when he took Peter back to the B&B as he felt his behaviour was not acceptable for a planned visit to the family home. Peter's body was found some hours later. The circumstances were plainly of a deliberate self-hanging.