What happened
A 17-year-old at a sixth form college in West Yorkshire was diagnosed with ADHD at ten and stopped his medication at about 14 over side effects, the BBC reported on 7 November 2024.
He was suspended on 11 April 2024 after an altercation, then permanently excluded after an investigation. His mother was told first; he was emailed. He was found dead on 21 April 2024, three days after the exclusion.
At the inquest in Bradford, college staff apologised for how the exclusion was communicated, calling it a learning opportunity, per the family’s solicitors’ release of 12 November 2024. It later told the coroner lessons had been learned.
The outcome
The inquest opened on 8 October 2024 and concluded on 31 October 2024 before Angela Brocklehurst, HM Assistant Coroner for West Yorkshire (Western), with a narrative conclusion. No charge was brought.
Her Regulation 28 report of 4 November 2024, reference 2024-0598, recorded no evidence as to whether the college’s safeguarding team knew he had stopped his CAMHS treatment on 13 November 2023, with his parents’ consent, or given notice of discharge from a recovery support organisation on 9 April 2024. His mitigation statement said nothing about his current mental health, and the college’s newest CAMHS letter was dated October 2023.
The college replied on 23 December 2024 that staff now request updates from outside agencies where a welfare plan exists or exclusion is a last resort.
What went wrong
The newest clinical letter was seven months old on the day of the exclusion, and he had left both services since it was written. Nothing shows anyone checked the date.
Nobody asked. The document he wrote himself carried nothing about his mental health, and his college’s system pulled no missing fact in from elsewhere.
The delivery was administration. The decision reached his mother, then him, by email, and the college’s own staff conceded in evidence that the manner was wrong.
What it teaches
Exclusion is a mental health event decided on documents. The question is not whether the exclusion was right, but what the decision-maker knew when deciding, and how they would prove it.
A date is testable. “CAMHS last wrote in October 2023” is a line a pastoral lead can check in a minute. The coroner found an absence of evidence, which inside a school means an absence of record.
Communication is part of the sanction, not the paperwork after it. How the decision arrives is a choice, and it needs a plan.
Questions for the room
- When your school decides to exclude a pupil, what is the newest clinical information on file, and who checks its date?
- When a family says a service has discharged their child, where is that written down, and who acts on it?
- If a coroner asked you to prove a vulnerable pupil’s mental health was weighed, what would you hand over?
Evidence and limits
Confidence: confirmed. The Regulation 28 report, the college’s response, the BBC’s report and the solicitors’ release listed below were all read live on 7 November 2026.
He is not named; he was 17. The college and the school he joined from are withheld, because the report, the BBC and his family’s campaign name him. His death is not described, and the evidence here comes through the BBC and the release, not a transcript. Not verified: whether the college’s changes were audited, or any response from the trust.
Our training in physical intervention and de-escalation treats the conversation before a sanction as part of the work.
Sources
- Courts and Tribunals Judiciary, 4 November 2024, report 2024-0598 · https://www.judiciary.uk/prevention-of-future-death-reports/ · its own address carries his name
- BBC News, 7 November 2024 · https://www.bbc.com/news/articles/c4gxezxw277o
- INQUEST, 12 November 2024, Ison Harrison release · https://inquest.org.uk/news-and-comment/press-releases/ · its own address carries his name
Reviewed 7 November 2026.