What happened
The pupil was 13, at a secondary school in South Yorkshire. He asked for his change of name to be passed to the school, which put him on its vulnerable register.
In November 2021 an incident on school premises that should have produced a risk assessment went unrecorded. A later disclosure of self-harm put him on the waiting list for the school’s counselling service.
On 15 March 2022 he gave a teacher a letter saying he wished to end his life. The safeguarding lead risk-assessed him, moved him up the list and told his mother to go to A&E if worried. Counselling began ten days later.
The counselling ended in May with a discharge email offering possible future benefit, no time frame, no enquiry. The referral to child and adolescent mental health services came on 27 June 2022. He died in hospital on 18 July 2022, four days after he was found seriously injured; the coroner found that what happened was unwitnessed and that his intent was not clear.
The outcome
The inquest concluded on 7 September 2023 with a narrative conclusion. The assistant coroner found identifiable individual failures in following the school’s processes, but not enough to amount to systemic failure, and no real and immediate concern the school could reasonably have acted on before his death.
She was concerned about the system. Her Regulation 28 report, numbered 2023-0380 and dated 10 October 2023, went to the Department of Health and Social Care and the Department for Education, with responses due by 5 December 2023. No charge was brought and no regulator has made a finding.
What went wrong
The NHS referral was not made, because the school understood a pupil receiving any other support would be taken off a waiting list running beyond ten months. The choice was school counselling or the NHS queue, not both.
The school bought its own psychology support, but the process for allocating it was not clear.
There was no route to refer a pupil in or to receive anything back at the end: the discharge email pointed at possible future work with no detail, and nobody enquired. The referral, when it came, was pre-emptive, not a response to immediate risk.
What it teaches
Buying support can quietly remove a pupil from the queue. The routes are not additive, and a pupil seen in school may be one the health service never assessed. The eligibility judgement lands on staff not equipped to make it.
Then the discharge. Sessions end, and unless someone owns what happens at the end, the case closes itself. The coroner asked what the school received, not what the counsellor said.
Questions for the room
- When your school decides not to refer a pupil to NHS mental health services, where is that written down?
- A counselling course ends with a discharge email and no plan. Who reads it in the first week?
- What would your referral record say to a coroner two years later?
Evidence and limits
Confidence: confirmed. The Regulation 28 report and the BBC’s account of the inquest conclusion were read live on 7 November 2026.
The child is not named, and the school is described only as a secondary school in South Yorkshire: the sources name both pupil and school, so naming the school would identify him. No staff member is named; none was convicted.
The coroner’s finding that the school could not reasonably have acted between May and July 2022 stands as she made it, not as an endorsement of the referral route she criticised.
Our physical intervention and escalation training treats the written decision and the route out of a concern as part of the response.
Sources
- Courts and Tribunals Judiciary, 10 October 2023 · https://www.judiciary.uk/prevention-of-future-death-reports/
- BBC News, 7 September 2023 · https://www.bbc.com/news/uk-england-south-yorkshire-66747020
Reviewed 7 November 2026.