Thread by @SammyInquest

I'm back in court on Day 9 of Sammy Alban Stanley's Article 2 inquest at Kent Coroners Court for the Coroner's summing up and conclusion

Asst Coroner Catherine Wood sits without a jury

Counsel for family is @Angela__Patrick instructed by @annam2341, for @Kent_cc is Jonathan Landau and for @NELFT is @AliciaTew

Court usher is just doing some introductions. Members of press online and in second court room. Members of Sammy's family in court.

[Just to say Coroner's summings up are notoriously fast and I'll be missing large chunks, but I'll do my best to report as much as possible]

Coroner: Just need to run thru the law on the basis that I've got some different individuals joined this time. In essence I'll just run thru the directions I need to as some individuals connecting remotely.

Coroner confirms three audio links granted and John Holland, Dr Qazi, legal representative from NELFT are also joining online.

Coroner gives warnings and permissions.

C: I'm now going to, this comes in three parts essentially, summarise the evidence, will only be a summary, would take 9 days to get to stage of repeating it.

C: Will summarise key aspects of evidence, explain a little about law and give details of my findings and why I find in the way I do.

C: we've heard from numerous witnesses... I'm going to group them together and I'll give a summary of the evidence we've heard.

C: Grouping together those who looked after Sammy's general health first.... GP, paediatrician at East Kent... heard orally from Dr Baker, local paediatrician involved in Sammy's endocrine management and Prof Dattani who provides outreach clinic.

C: Evidence heard from all of those Sammy had known diagnosis of Prader Willi Syndrome, noted very early on in his development. Also diagnosed as suffering from anxiety and autistic spectrum disorder.

C: Coroner will focus from 2019 onwards, Prof Dattani first saw Sammy on 11 Jan 2019

Prof D gave background of PWS and Sammy's mother @PAlbanStanley in her evidence gave detailed explanation of how affected Sammy.

C: Known impact on brain... clearly neuro cognitive disability that sits within known diagnosis of PWS. His evidecne was this was known to worsen at adolescence, particular consequence in this case given Sammy's age.

Prof D saw Sammy on 11 Jan 2019 and again on 3 Feb 2020...

C: Was deemed by him that he required more help. He was asked about psychological treatments and medication... his experience drugs didnt usually make very much difference, drugs and psychology dont always alleviate the symptoms but may improve some

C: said clear teenage years particularly difficult... most problems known about more relation int food and dietary issues, less of a problem because of the exceptional management of Sammy by his family in that regard, particularly his mother.

C: C: She'd made it so much of a non problem for Sammy he managed to eat a healthy diet and lifestyle...

He also gave evidence he'd never seen a death in such circumstances.

C: Asked about type of death occurred, no evidence of death in such circumstances in literature, often physical health problems such as diabetes and associated over eating

C: He said he made referral to Prof Santosh at Maudsley in 2020, didn't consider needed at earlier stage. Prof Santosh may have been able to assist.

C:He also gave evidence its not infrequent for him to see children with disabilities, not only PWS, who need to have more support and LAs were often reported to him by parents as being inadequate.

C: He considered more needed to be done to support young people and their families, particularly those with rare conditions affectign the brain.

We also heard some bacground evidence from other clinicians, but predominatly Prof D evidence key in this case.

C: We heard as well from two members of the teaching profession, one directly involved with Sammy and one not. Ellen Rowe was headmistress of school where Sammy's siblings attended... explained impact directly on children she was responsible for.

C: She'd made referrals to social services because of these behaviours, concerns about how risks could be managed.

We heard quite detailed evidence from John Deslandes at Laleham Gap, I have to say I was very impressed by Mr D evidence.

C: I considered he had provided a really detailed chronology of what happened, also impressed by the way the school had supported Sammy and his family during the time he was with them.

C: Sadly that time was short as he was only attending between March 2019 and March 2020 because period of over a year where Sammy was not provided by appropriate educational support by the local authority @Kent_cc.

C: His mother had to fight for a placement that Sammy clearly needed. He was placed in right school in Mar 2019 and Mr D gave evidence of universal support strategies school provided to help Sammy with his needs.

C: Incidents at school when happened well managed, often took a couple member of staff to contain Sammy.

There was no doubt he was happy at school, yes there were incidents of risky behaviour but these were dealt with appropriately.

C: Social services were involved and told about these incidences.

What was real concern during march 2020 was several incidents of concern with Sammy, one of particular concern where wasn't warning.

C: Was one episode when he'd been to bathroom and calmly swallowed needle. Showed Sammy's behaviour was becoming more difficult to manage.,. earlier signs of Sammy becoming agitated, concerned or heightened, concern was this was in a calm moment.

C: I'll now discuss social work aspect, we heard from three social workers Chloe Berry, Sarah McCormack and Siobhan McAree.

We heard how Chloe B first became involved in late April 2018 and having become involved with Sammy's care...

C: almost immediately after her involvement contacted the Children with Disabilities Team after concerning incidents. Had email correspondence with Sandra Power in CWD Team this was a refusal to even assess Sammy to see if fitted their criteria, she said he needed CAMHS support.

C: CB was hearing CAMHS didn't consider this was a mental health issue. She was asking for advice. She wasn't told at that stage of various options available to Sammy and his family.

C: She wasn't told Mrs AS could apply for carers assessment... apply for support financially thru Direct Payments... wasnt told could be application for respite or other assistance in that regard. Despite asking for advice this wasn't given to her.

C: CB was not familiar with dealing with children with disabilities but was trying her hardest to provide support to the family.

Were several Child in Need Meetings convened by Miss B, 5 June 2018, Niall Johnson from CAMHS @NELFT attended.

C: CWD Team invited again... they declined invite and so did Kent SEN. At this stage Sammy wasn't in education and no-one from education attended that meeting. Was essentially just between mental health, Sammy's family and social worker.

C: Further CHIN 9 Aug 2018 and Neil Johnson explained some changes to Sammy's medication.. on 21 Sept 18 further CHIN meeting, at this stage Mrs AS had managed to get some back up support for herself, she'd investigated and managed to get some funding from a charity.

C: She explained at Sept meeting the charity funding for mindfulness therapy had been paid for and was going well and Sammy was benefitting from that. Also referral for Mrs AS to go on parenting course for parents of children with ASD.

C: No further involvement from 10 Oct 2018... in March 2019 Sarah McCormack became involved in Sammy's case. By now Sammy had a school place... even with support at school was clear he still needed extra support outside school day for family.

C: Involvement of SMcC came after re-referral when head at Sammy's siblings school had contacted social services @Kent_cc. She realised support needed in place for family, made enquiry about short breaks.

C: Told was Section 136 on 23 April 2019... was 2hrs support provided by PA funded by charity... was having some mindfulness therapy by that stage. She undertook child and family assessment, process required to have agreement for DPs.

C: Made application for DPs put in place for 3hrs day for 5 days week, 2hrs after school and hour before. Times when busy household needed extra support for Sammy because of his needs directly related to his disability, his PWS.

C: 17 June CHIN meeting, panel on 19 June was refusal for that support requested, despite going thru full process. SMcC then escalated thru management and finally achieved agreement on 11 July for 2hrs a day support.

C: Less than support requested but at least this was something... 2hrs day funded by DP.

We then heard she left and Siobhan McAree became involved. First involvement was CHIN meeting on 27 Sept 2019 with John Deslandes because Sammy in education and social worker involved.

C: She noted DPs were to be explored and a family group conference considered. On 9 Oct she made referral for DPs.

Evidence subsequently was events with needle swallowing, event in Nov and again Dec. She was aware at CHIN meeting on 8 Nov

C: Sammy had been making threats to kill himself while he was having problems, in heightened episodes would make such threats and requirement police become involved.

Also considered, she herself, should be discussion with CWD team again.

C: She was told he didn't meet the criteria. Noted further police referral on 17 Nov with threats to kill himself, further CHIN meeting on 11 Dec, CAMHS didn't attend, neither did Dr Baker, no medical attendance at that CHIN meeting.

C: At this point she was still following up DPs. Altho agreed 11 July by 11 Dec still no DPs in place

January CHIN no attendance from CAMHS. Finally in January PA was cleared to start work.

C: Notified referral to Prof Santosh in late January and further reports of referrals from @kent_police in January.

Gap between Feb and March 2020 because Ms McAree was not in work during that period.

C: By 16 March she was aware was even less social support than family had because less involvement from other adults around that stage.

Was liaison on 18 March that was going to be issues because of covid, and was going to be no schooling.

C: Was told 26 March Sammy had been advised to shield. Also been attempt to jump off Ramsgate Harbour. She spoke to Dr Hanney from CAMHS and liaised with Police about responses.

C: Advised Mrs AS she could use surplus hours built up. Further contact on 12 May [?] by Kent Police. CHIN meeting held on 17 April 2020.

C: At that CHIN meeting was clear number of incidents had significantly increased, Sammy was known not to be in school, hours in school day no longer filled.

C: Was suggestion possibly may be increase in DPs but no action was taken and no practical support was provided to Sammy and his family following that meeting.

C: Would have been difficult for Mrs AS to agree to use surplus support given she knew it was time limited and had been such a struggle to get it.

Now look at mental health service involvement from 2018 when Sammy moved to Kent.

C: We heard Niall Johnson and Dr Al Kadi were two clinicians involved in Sammy's care from Feb 2018. Involved after urgent referral made because of concerns and discussion of referral from CAMHS in Surrey.

C: I was very impressed with Mr Johnson's evidence who clearly tried his best to support the family throughout. He had regular involvement but was limited in what he could offer.

C: Dr Al Kadi appeared to mainly review and discuss medication, saw on few occasions, gave advice on monitoring drugs and changed some drugs. His evidence was he knew about Prof Santosh at Maudsley but didn't consider referral at that stage.

C: Discussion of referral to neuro developmental pathway @NELFT but at that stage NELFT were only commissioned for pathway for diagnosis, and not treatment. Sammy already had a diagnosis so no treatment available to him on that pathway.

C: All available to him in treatment was that which could be provided by mental health arm of the Trust, not the neuro developmental pathway. He wasn't offered any CBT, all he was offered was some drugs.

C: The real difficulty for clinicians was fact these behavioural issues, or issues when Sammy had self harmed.... particular instances didn't happen when he was calm. So there was no discussions with Sammy that he'd have suicidal ideation which was difficult for them to reflect.

C: Clinicians were all pushed on their risk assessments for Sammy. Clearly when he was calm he wasn't at risk. His risks were minimised because he had such amazing parental support. His mother was able to deal with the behavioural issues as they arose and deescalated those issues

C: When he was calm, seen at clinical appointments, no-one saw him in heightened episodes so was difficult for clinicians to assess.

The only people who'd seen him in episodes, other than his family were the Police... and those at school.

C: They had fed back into various meetings, back thru into social services, had explained real concerns about Sammy and managing to keep him safe.

C: They were saying all the way thru they'd seen these episodes and were very concerned, particularly when lack of schooling would play part in beginning March 2020 with impact of covid

C: heard from John Holland and Dr Qazi, first involved in Feb 2020. JH being CPN, Dr Qazi was locum consultant... almost saw episode, Sammy's mum was clearly struggling at this consultation and asking for help.

C: Discussed potential, without upsetting Sammy, about whether he may need to go into residential care. Sammy became upset, JH used grounding technique with him and was able to calm him down.

C: Dr Qazi noted Sammy had low mood, problems with sleep, anxiety and impulsive behaviour as part of PWS. He considered his risk to be medium, because prone to extreme mood swings. Did consider was low risk of self harm.

C: Dr Qazi referred to Sammy's predictable unpredictability, that was referred to a lot s we went thru evidence. Was known when Sammy was in heightened episode was clearly at risk to himself.

C: He didn't understand risks, was very unpredictable, but when calm at low risks of self harm

Following meetings was discussion about CETR and contact made by Mr Holland with Laleham Gap. Went to see school on two occasions.

C: March MDT noted high anxiety levels, CETR process started, one can only surmise this was started but unfortunately very little was done to actually commence that process.

Was discussions about it but nothing was actually put in place.

C: 17 April was CHIN meeting and unfortunately Mr H wasn't able to attend because of technical difficulties but fed into it..

C: I have to say I was quite concerned of some of the evidence I heard from Dr Hanney... trying to assist but clear she hadn't attained a full picture of Sammy, hadn't read his notes in any great detail.

C: Was clear she was trying to assist but I was concerned she wasn't aware of his history,

She was trying to move things forward, she wasn't treating clinician.

C: Some discussion of CETR process and non violent resistance being offered to Sammy's mum, which was delayed because of covid.

She also gave advice to police about how deal with Sammy and contacted Dr Qazi and had discussion about treatment.

C: What was clearly clear throughout this process, those at Trust and social services and school were all aware Sammy's risks were increasing, and likely increase further given pending lockdown.

I heard from two management individuals involved and read some other evidence.

C: Heard from Roger Smith who accepted throughout that.... accepted even though deemed by Sandra Power not even suitable to assess, she considered he didn't fit criteria, but Roger Smith first set off saying he didn't fit criteria, he did accept criteria could be interpreted...

C: in such a way that Sammy did fit. He said was difficult to see what difference would make because same things were available.

However children's social work team weren't aware of them, the CWD team were. they didn't give advice, weren't forthcoming...

C: Matt Dunkley confirmed management could have approved DPs and a carers assessment, this was available all the way thru.

C: Dont need cover further from his evidence, were changes as consequence but those on shop floor so to speak, acting and looking after Sammy weren't able to provide that support.

C: I called DS Culpin from @kent_police he provided evidence of lots of involvement with Kent Police over preceding two years and discussed how police would be rightly part of the emergency response to support Sammy and family when having episode. They were involved.

C: He also gave evidence about event of 22 April. Read from evidence of witnesses.

Also explained how, and we heard from Mrs AS how Sammy had got up early that morning, around 6:30 he was very concerned about correspondence from bank,

C: family bent over backwards looking for correspondence, found it and gave it to Sammy.

Later realised correspondence may not have been what Sammy was looking for.

C: He calmed down, went downstairs for his breakfast... just before 7am Sammy was seen by passers by who spoke and approached him, was on wrong side of railings.

They tried to speak to him but sadly he slid back, having undertaken high risk activity as consequence of his PWS.

C: Then read evidence from clinical reports of injuries Sammy sustained from consequence of falling backwards from cliff face.

Sadly he died on 25 April. [Actually 26th, corrected later]

Heard evidence of changes... wont deal with now.

C: Will finish in my summary of evidence, the final paragraph from Sammy's mother's evidence. She said Sammy was a beautiful soul, an absolute pleasure... he fell thru cracks in system because deemed not disabled enough to be awarded proper level of care yet too disabled for me..

C: and my young daughters to manage at home... did all I could to give him a wonderful life and maximise his opportunities but feel badly led down by authorities who should have helped us seek specialist support to ensure Sammy continued to live a fulfilling and happy life.

C: I now have to look at the law, in regards to the law the framework is bound in Section 5 of Coroner's and Justice Act.

I need consider who deceased was, how, when and where and in this case what circumstances Sammy came by his death.

C: Need consider whether or not any failures in care provided to Sammy by those agents of the state.

Whether or not system failure by @Kent_cc in dealing with children with disabilities. System in place in Kent meant Sammy was deemed not to fulfil CWD criteria.

C: It was a flawed system which did not have regards to difficulties Sammy faced as combination of his PWS and ASD in conjunction with his anxiety.

C: Had he been recognised as fulfilling their criteria, team involved with care would have been far more familiar with what was available to a child with a disability...

Social workers were not assisted by CWD team who simply tried to shift the focus to CAMHS.

C: I consider there was a failure in the system @Kent_cc that played a part in Sammy's care.

C: Also need to consider whether any failures to recognise risks Sammy faced as consequence of his PWS and ASD.

@Kent_cc were fully aware during behavioural episodes Sammy was known to put his own, and his family's lives, at risk... Sammy clearly in risky age group.

C: Risks due to PWS were predictably unpredictable... although Mrs AS considered risks greatest before and after school in busy household. His mother did her upmost to keep Sammy safe... with help from police...

C: at age 12 Sammy had had two incidents where Section 136 powers needed to be used. That must have been very frightening for him and distressing for family and siblings.

Incidents increasing <Coroner gives examples>

C: Coroner lists CHIN meeting occasions where CAMHS didn't attend... only incidents after Sammy was in school

Mrs AS having to call police almost daily... Mrs AS told Dr Hanney episodes were escalating....

C: April CHIN... by now everyone knew Sammy was not going to be in school... several episodes due to his PWS condition which meant police were called, while Sammy was still in school.

Was clearly going to be more incidents or less support available.

C: It was obvious this family would need more support.

Possibility of going to panel for increased Direct Payments was discussed but no direct actions were taken.

C: on 20 April Sammy made comments of wanting to end his life.

On 22 April he was RAG rated because he wasn't in school and his behaviour was escalating...

C: What opportunities were missed to reduce the risk to Sammy?

Heard evidence was quite clear behaviour was escalating. His Mum was raising concerns about him.

In 2019 social worker was aware Sammy needed more help but no steps were taken.

C: In March 2020 the social worker considered Mrs AS was "at the end of her tether", yet still nothing further was done.

Discussion of possible avenues to support [?], but that was of no assistance when the family were calling out for practical support.

C: This family were desperate to try keep Sammy at home.

The alternative would have been a residential placement which clearly would have cost the local authority significantly more than investing a little time, effort and resource into supporting this family at home.

C: Was clear evidence Sammy required support at school and at home... as well as possibly by considering CBT and non violent resistance training.

C: Its difficult to know, to what extent this or any of options may have assisted but we have heard how Sammy responded well to mindfulness... he had 2 hrs day during week but at that stage had school support as well which clearly helped reduce his anxiety

C: I therefore conclude was failure by @Kent_cc to provide suitable school place on his arrival in Kent... this school place if provided earlier may have assisted Sammy in establishing strategies he was likely need to mange his disabilities

C: @Kent_cc also failed to provide sufficient support outside school, as well as carers assessment and respite care... consequence is his dedicated mother did not have support to deal with consequences as a direct result of his disability

C: at the beginning of lockdown @Kent_cc social work team, despite being aware Mrs AS needed more help, did not provide any much needed support.

Instead simply suggested use built up hours accrued due to lengthy process in finding support worker.

C: There were clear failures in relation to what was provided by @Kent_cc to Sammy and his family.

I also find there were failures in relation to healthcare offered to Sammy by @NELFT.

No therapies were offered during entire period he was under the care of the Trust.

C: In Feb 2020 no new interventions were considered, and no available treatment pathway for neuo developmental service at @NELFT.

A CETR was considered but had not been commenced and NELFT had been made aware of all the details.

C: the evidence of John Holland was given risk he probably should have had weekly face to face meetings during 2020.

Again whether would have made difference was difficult to say, what was really needed was help on daily basis.

C: I dont however consider not referring to Prof Santosh at earlier stage was failure in this case.

There were also failures in communication between healthcare and social care teams....

C: C: also satisfied that once support withdrawn due to Covid 19 was failure to recognise obvious increased risk to Sammy would mean he needed more, not less, support. Failure by all state agencies to take steps...

C: However, acknowledging all those failures, I need to look at causation. Test I need to apply is whether on balance of probabilities failures in question more than minimally or trivially contributed to Sammy's death.

C: Heard what eventually happened could still have happened even with more support in place.

Not one witness was able to say failure to have support more than minimally contributed to outcome.

C: On that basis I don't get over hurdle these were probably causative... can not be said to be probably more than minimally or trivially contributed to his death.

On basis I dont consider failures probably more than minimally, negligibly or trivially contributed.

C: I'll address neglect raised by family... there must be clear and direct causal... conduct must have caused the death in sense more than minimally, negligibly or trivially contributed to the death...

C: touchstone is opportunity of rendering care that would have prevented death.... must be shown care should have been rendered and would have prevented or prolonged life.

C: Dont consider have evidence, do accept failures in care, Sammy was clearly in dependent position.... simply dont get to causation stage for neglect

Need consider possible failings...

C: Lewis is case where I have discretion to record matters that possibly made more than minimal contribution to death

I am satisfied on the evidence its at least possible, if not probably, that failure to provide extra support to Sammy and his family contributed to his death

C: I turn now to how I should record my conclusion, short form is inadequate...

Complexity of key issues, including my findings of possibly causative failings... discretion include matters that possibly contributed to death... agreed by counsel for family and KentCC

C: Inconsistencies in case law... judgement in Carole Smith very difficult to reconcile with Tainton....

from public record point of view transcript only available on application to court is insufficient [I think]

C: I can not see how Article 2 duties will be met, nor court intended two sets of standards in jury and non-jury cases. Counsel for family and KCC agreed position is clear.

C: I therefore find in following way... inquest opened 4 May 2020... heard before myself Catherine Wood in Coroners Area of Kent

Find name of deceased is Samuel Robin Alban Stanley

Accept cause of death is 1a traumatic brain injury

C: in relation to how, when and where and in what circumstances... I find that Sammy, in fact before I make these findings do you want me to refer to Sammy throughout on record of inquest or full name Samuel?

JL: [cant hear]

AP: [cant hear]

C: then I'll refer to him as Samuel in this instance incase any problems coming back

Sammy Alban Stanley suffered from #PWS in box 3, known to be associated with behavioural problems and he was also diagnosed as suffering from ASD and anxiety

C: behavioural characteristics in children with #PWS are described as being suggestive of autism [?] and prone to increase with age

As Samuel got older his behavioural problems increased leading to episodes of extremely high risk behaviour impacting on both him and his family

C: In such episodes he made threats to end his own life, but when he was calm denied any suicidal ideation.

He'd made attempts to jump out of moving cars, building windows, had run into the sea in an attempt to drown himself and threatened to jump off Ramsgate Harbour.

C: His behaviour was at times so extreme that his family needed the assistance of the police to stop Sammy from hurting himself or others around.

C: However when not in heightened emotional state he was a loving, caring little boy, cared for by an exceptionally dedicated and caring family.

C: Sammy and his family moved to Kent in 2018 and he was without educational provision until March 2019, following appeal against decision for him to be in a mainstream school, so he could attend special school that catered for his specific and complex needs

C: The school offered support to reduce his anxiety and strategies in place to deal with high risk behaviour when distressed. Despite challenges he was happy at school, high risk episodes were precipitated [?]...

C: until episode 10 Dec 2019 when calmly returned from toilet having swallowed needle.. at school, occasions limited, but staff had concerns when they did occur everything in his vicinity was a risk to him.

C: Concerns about his behaviour had been shared with social work team, where he was open to them as a child in need, and mental health team involved with Samuel's care

C: of note is Children with Disabilities Team at @Kent_cc had chosen not even to assess Samuel as they considered on paper he did not meet their criteria.

C: As consequence Samuel was seen by social workers from children social work team who were unfamiliar with range of services that could have been provided to a child with disabilities and their family

C: First referral to CWD was made in May 2018... even in 2020 further attempts to have that team involved in Samuel's care were unsuccessful

C: Failure to have specialist support and advice meant Sammy and his family did not have access to range of support which may have ultimately had an impact on his life....

C: if earlier support and school placement at earlier stage, risk associated with his #PWS episodes, may have been reduced.

C: The teams at both @Kent_cc social services and @NELFT were aware that during an episode Samuel was at high risk of harming himself and undertaking life threatening behaviours in past

C: Samuel had been known to respond well to mindfulness therapy and de-escalation techniques used by his family and other professionals that had worked in calming Samuel. But at times police attendance was required to keep Samuel and his family safe.

C: psycho social interventions were not offered which possibly would have reduced the risk to Samuel, as the mental health team treating him did not consider they had such resources available to them due to commissioning arrangements and staff shortages.

C: When options such as CETR and non violent resistance training were considered, they were not implemented in a timely manner. Therefore Samuel and his family were deprived of opportunity to see if such interventions could have made difference.

C: Also failures in communication between various agencies associated with Samuel's care.

C: Had information been shared in timely manner, and action take as result, then is possible more support could have been provided to Samuel and his family which may ultimately have made a difference to his high risk taking episodes, and ultimately his death.

C: A letter arrived at home on 20 March 2020 which stated Samuel should shield due to vulnerable effects of covid 19 and #PWS... his mother contacted social services and said would need more support at home.

C: CHIN meeting on 17 April led to discussion about options but no actual support was initiated to reduce risk to Samuel of not being in school

C: on 20 April 2020 police were called asking for support and Sammy was heard to be shouting he wanted to kill himself.

On 22 April 2020 Samuel woke early, and became distressed about missing communication which was thought to be found.

C: he appeared to settle down, and went downstairs for breakfast... he left the house and climbed over railings at upper promenade on Victoria Parade Ramsgate. Passersby tried to engage with him but he fell backwards from the cliff shortly before 7am...

C: He was taken to Queen Elizabeth Queen Mother Hospital and subsequently Kings College Hospital... died from injuries he sustained on 25 April 2020 [actually 26 April, later corrected]

C: narrative conclusion and reads in conjunction with Box 3.

C: Samuel Alban Stanley died as a consequence of injuries sustained during an episode of high risk behaviour related to his Prader Willi Syndrome, on the background of inadequate support from local authority @Kent_cc and mental health services @NELFT.

C: Just check I've got the right particulars - date of birth and place of birth, name and when died, they've got 26th, apologies, for some reason I've put 25th.

I'll amend that to 26th.

C: Was student at the time of his death, son to Patricia and Barry Alban Stanley and last known address

All remains to do is thank those who assisted Sammy during his lifetime. Thanks to those who gave evidence throughout inquest

C: I was particularly impressed with respective evidence from those who'd tried to learn from Sammy's death.

C: I hope the fact some steps have been taken to try reduce risk to others is of some comfort to Sammy's family, altho clearly that will never bring Sammy back or cope with loss you feel, but hopefully others wont feel same struggles as you did

C: I do consider I need to write a Prevention of Future Death Report because I dont consider a local response is sufficient. I will be writing a report because I do consider there are still some gaps and still some risks to others going forward...

C: therefore I will be writing a prevention of future deaths report. In terms of that I will share that with you, I have some time to write that.

C: I also want to thank counsel, and those who sit behind them, for their assistance throughout the inquest. Their thorough assistance and questioning of witnesses that has assisted going forward which helped explore some of issues surrounding Sammy's care and treatment.

C: Thank you to all of you for your assistance

Finally, but perhaps most importantly, I turn to Sammy's family and offer you my sincere condolences on your loss. I can not imagine anything worse than losing a child, must be one of the worst things any parent could face.

C: I hope the inquest has given you the answers to some, if not all of your questions, and with this behind you you can take steps to rebuild your lives without Sammy in them.

C: I'm sure life will never be the same again but hopefully some of your answers to questions were answered thru this process. Once again my sincere condolences to you and all of the family.

AP [cant hear]

C: Thank you. Thank you all and I hope you have a pleasant afternoon

JL: copy of your summing up [I think - cant hear]

C: it's in note format so I don't have a complete copy, obviously you can ask for a copy of the recording for today if needs be. Thank you very much for your assistance.

Sammy's inquest closed at 12:04.

I'll tweet a family statement later.

Now I'm moving to @CocoInquest

With my repeated thanks to those who have read, shared, commented and donated to support by reporting from court chuffed.org/project/openju…