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Referral failures lead to teenager Oskar’s suicide

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Oskar Nash, who had Asperger’s Syndrome, had been demonstrating signs of mental health problems and talking about suicide since he was six years old, but his devastated family had not been helped.

A letter from Relate, offering to see the teenager, arrived the day after he died and on the day his body was found.

Relate – as part of its work – helps teenagers and parents who fall out with each other. But it is not equipped to deal with mentally unwell children.

Surrey coroner Richard Travers said that had Oskar been seen and treated he would probably still be alive. The failures were so bad that he ruled the youngster had been denied the “right to life” enshrined in the Human Rights Act.

The inquest heard how Oskar had been let down by social services, schools and Child Adolescent and Mental Health Services (CAMHS) as far back as 2016. He had never been properly assessed by child psychiatrists and psychologists.

In the months leading to his death, a GP urgent referral letter was ignored and his needs classed as “routine” without a referral to a clinician. Finally, after a wait of four months, he was referred to the counselling charity Relate which was not equipped to deal with his needs.

The letter from Relate was delivered to his mother’s home on January 10 last year. The day before, the youngster had taken his life on a railway line at Egham in Surrey.

The referral was “inappropriate” and was made without a proper assessment, the inquest heard. After the tragedy Relate said it would never have accepted Oskar had it known his history.

Next month, Mr Travers intends to issue a “prevention of future deaths” report, demanding changes to halt more tragedies.

Oskar had been “tortured” by thoughts of suicide for many years. In the months and weeks before his death he had been displaying signs of stress often associated with suicidal thoughts. Although he had been diagnosed with autism, at the age of four, his mother said her son had never been properly supported.

In December after several calls pleading for help, his mother, Natalia Nash, got just two minutes on the phone with a CAMHS worker who believed Oskar’s needs were not serious and so asked Relate to help. Anna Moore, of lawyers Leigh Day who represented the family, said: “It’s ironic and dreadful that Oskar’s mum got that letter from Relate on the day his body was found.”

Mrs Nash, a financial analyst, from Staines, Surrey, said: “How could they refer a suicidal child to another organisation without carrying out a proper assessment first? I’d been asking for help and if that help came then there was a chance for him to be here, to be alive, for us to still be a family.”

Mr Travers said there was no fault on the part of Oskar’s mother, who has one other son, who brought him up on her own after his dad died, and “did her very best”. But she had not been supported from those whose job it was to protect children.

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Mr Travers said: “I am satisfied that timely and expert clinical intervention, following the September 2019 referral to CAMHS, would, more likely than not, have minimised his level of suicidal ideation and avoided his death in January 2020.

“Oskar was a child in need of skilled, professional support, which he did not receive.”

Dr Justin Wilson, Chief Medical Officer at Surrey and Borders Partnership NHS Foundation Trust, said: “We’re devastated by the events that led to Oskar’s tragic death and express our sincere condolences and apologies to Oskar’s family.

“Significant changes have taken place to key aspects of how cases like Oskar’s are handled.”

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