There were failures in the treatment of a teenage Wem school pupil before he ended his life, a senior coroner has ruled.
Jeff Antwis, 14, died at Royal Stoke Hospital on January 30 this year after he was struck by a train at Harlescott crossing at 5.30am, and he had Autism Spectrum Disorder, also known as Asperger syndrome.
John Ellery, senior coroner for Shropshire, concluded his death was suicide at an inquest held at Shrewsbury’s Shirehall.
However, Mr Ellery believes the decision five days before, on January 25, by Dr Ini Oknna, of Shropshire’s Child and Adolescent Mental Health Services (CAMHS) not to place the 14-year-old in urgent care, but to be seen in a routine appointment, could have possibly led to Jeff’s actions.
If he had been classed as urgent, which Dr Nina Champaneri – an independent consultant instructed by Mr Ellery – said he should have been on the evidence she had seen, Jeff’s next appointment would have been around January 27, not March 17.
In summing up, Mr Ellery said: “There was a shortcoming and failure as to how Jeff was treated.
“I do also acknowledge there were good elements of practice such as timing (of intervention) up to and including Melanie Archer (who was a locum nurse who assessed Jeff).
“But once he was classed as routine and not urgent, I will record (as a failure).
“I am convinced he tried to commit suicide and that he intended to do it, on the established evidence.
“I cannot say if such a meeting on January 27 would have stopped Jeff killing himself but without a doubt it would have helped. However, one meeting alone getting to the bottom of his problems is speculation.
“It’s possible an earlier appointment would have lifted his spirits and would have been an earlier step in helping.
“In a matter of law, I can only say it may have helped.”
Mr Ellery also recorded it wasn’t a gross failure and that it did not cause or contribute to his death, but that it possibly did.
He added attention should have paid to the fact Lorraine Antwis, Jeff’s mother, believed he wanted to harm himself, as did the family GP Dr Bindu Praveen, as well as Miss Archer.
He added Dr Champaneri’s findings matched his own, non-medical, feelings that Jeff’s voice, given through a ‘miracle question’ assessment that he wanted to die, were enough for him to be seen within seven days.
Mr Ellery also took issue with Miss Archer’s advice to Ms Antwis that she should write to complain about the March 17 appointment.
Sharon Conlon, Clinical Implemtation Lead for 0-25 Emotional Health and Wellbeing Service at South Staffordshire and Shropshire Trust, which is now responsible for CAMHS, had earlier told the hearing this was not standard procedure.
The coroner added he would sending a report on the hearing to the trust to prevent future deaths.