After the death of an 18-year-old trans man, Axel Matters, who took his own life, a coroner has concluded that the mental health and social care services contributed to his passing due to neglect. Axel, who lived in Brighton and was considered to be at “exceptional risk” of self-harm, was discharged from the hospital without a care plan, which was deemed a failure by the West Sussex Coroner, Penelope Schofield. The services also failed to assess whether Axel would be safe living on his own.
Giving a narrative conclusion, Ms Schofield stated that Axel was discharged from the hospital in February 2021 following his arrest by the police. Agencies failed Axel in a number of ways. Mental health services did not provide a clear risk, crisis and care plan on discharge. Adult social care failed to provide a timely assessment of Axel either at the time of his discharge or thereafter. The appropriateness of Axel’s accommodation was not considered for someone who was unsafe living alone. His lead practitioner, who was not able to assess his ongoing risk, did not meet or engage with Axel after his discharge. On 6 April, when his mental health deteriorated, social care staff did not recognize his ongoing risk or check his worsening condition. Furthermore, lack of engagement with Axel while his care was transferred between services in Crawley and Brighton was reported.
Axel was found dead in a flat in Surrey Street, Brighton, shortly after his 18th birthday. At the moment, responsibility has been taken for the failure by the services to check on Axel and provide a proper care plan. His death has become the latest in a series of self-inflicted deaths unjustly affecting trans persons, and has highlighted the need for better mental care services for those in crisis in the LGBTI+ community
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