Before HM Area Coroner Kate Bisset

Lancashire & Blackburn with Darwen Coroner’s Court, Fulwood, Preston

18-19 and 23 January 2024

Max Sumner, 17, took his own life on 13 May 2022 while he was under the care of Lancashire and South Cumbria NHS Foundation Trust Child and Adolescent Mental Health Service (‘CAMHS’).

The Coroner concluded today (23 January 2024) that the care he received by CAMHS contributed to his death.

Max was born and raised in New Longton, Lancashire. He had a love for drama and performance and was a talented artist. When he was 16, Max told his dad he wanted to be known as Max and for people to use male pronouns when referring to him. Max was exceptionally proud of his trans identity and used every opportunity to champion LGBTQ+ rights.

The Coroner opened the conclusion hearing by saying, “Max Sumner was a much-loved son, brother, nephew and friend. He was and remains truly loved. His death is an appalling tragedy for which I offer my sincere condolences to his friends and family.”

In the last two years of his life, Max struggled with mental ill health, self-harm and suicide attempts. Max described himself to mental health practitioners as being in extreme emotional pain and regularly told CAMHS and Childline that he was thinking about suicide. In November 2021, Childline breached Max’s confidentiality three times due to concerns about an imminent risk to his life. Childline referred Max to CAMHS again in March 2022 but none of these actions resulted in a referral to Children’s Social Care or a Mental Health Act assessment. A Trust serious incident investigation found that Max should have been seen as a child in need of protection from November 2021.

The inquest heard that the records of Max’s final two contacts with his CAMHS case manager were entered onto the electronic system after the case manager received a suicide note from Max by email. The email was sent on 13 May 2022 but only seen by the case manager on 14 May 2022 due to annual leave. Despite regular email communication from Max, the case manager’s emails were not forwarded and despite a pattern of increase in risk while the case manager was on leave, there was no contingency plan or co-worker to support Max.

Tragically, Max did not want his family to know about the pain he was experiencing and CAMHS did not tell his parents the extent of his suicidal ideation and self-harm.

The Coroner endorsed the conclusion of the Trust investigator that there were 13 failures with Max’s care:

  • Clinical and managerial supervision was not facilitated;

  • Safeguarding supervision was not utilised;

  • Non-compliance with safeguarding and clinical risk training;

  • No evidence of a multi-agency safeguarding plan;

  • No children’s social care referral;

  • Missed opportunities to discuss Max at a multi-disciplinary team meeting;

  • No evidence of care planning or safety planning;

  • Risk assessment not reviewed;

  • Emails from Max were not shared;

  • Max’s family were not involved;

  • No formal diagnosis was pursued and Max had no care or treatment pathway;

  • There was no follow up of his ADHD assessment;

  • No evidence of multi-agency working.

In addition, the Coroner found that the safety plan which was discussed and/or in place for Max was insufficient as it contained features such as calling the CAMHS crisis line, something which Max had never done and there was no indication that he ever would have done.

The Coroner found that Max’s CAMHS case manager “kept Max to himself. He did not share Max’s presentation, he did not escalate concerns and he did not involve higher chains of command. This meant that he was the only person with the WHOLE picture of Max’s needs and any judgement calls about how to keep him safe landed on HIM ALONE, a situation which should not happen and should not have been allowed to happen. The responsibility for that does not lie with [the case manager] alone. Supervision should have been sufficient to understand that a highly complex young person, who [case manager] saw frequently was not on the radar to any other staff member.”

The Coroner concluded that Max died by suicide and returned a narrative conclusion. In her ruling she said:

  • “I find that the failings as set out in the trust investigation report, cumulatively, left Max in a position where no practitioner had all relevant information to assess the risk at which he presented. I find that by March 2022, when Childline without consent referrals had been received and Max had spoken to a [CAMHS duty practitioner] twice within 2 days, once assuring his safety and then less than 48 hours later having attempted suicide, By March 2022 at the latest Max ought to have been escalated to children’s safeguarding, he should have been considered for inpatient admission and if necessary a mental health act assessment and his confidentiality ought to have been breached in the interests of his safety.”

  • “From March 2022, the ONLY known protective factor against Max’s suicidal thoughts was the physical presence of his father in the family home and I accept without question the evidence of Mr Sumner that had he known of Max’s suicidal thoughts he would not have left him alone.”

  • “At the time of Max’s death, there was no up to date and accurate assessment of his risk, no involvement of safeguarding services, no multi-disciplinary team review of his needs and his family was unaware that he had repeatedly attempted suicide and had continuing thoughts to die.”

  • “I therefore conclude that had Max’s care been different, in particular had his confidentiality been breached in March 2022, along with escalation to children’s services and discussion of inpatient treatment, it is more likely than not that Max would not have died at the time at which he did because he would not have been afforded the physical opportunity.”

  • “I am not able to say what would have happened to Max if his care was different. He may or may not have been admitted as a voluntary or involuntary patient. He may or may not have received a diagnosis and if he did, that may or may not have resulted in some comfort or stabilisation for Max. His mental health needs were complex and may have gone on to be enduring. But I am satisfied it is more likely than not that Max’s care contributed to his death.”


The Coroner recorded Max’s sex as male, which is thought to be the first time this has happened for a trans teenager.

Steve Sumner, Max’s father, said: “When Max first attended CAMHS he was just 16. When he took his own life, he was 17. He was still a child. He was my child. I was and still am his father and as such I should have been informed at the very least as soon as the first attempt at suicide was reported. By not informing me of the severity of the situation: I not only lost my child in a way no parent should, I was also deprived of the opportunity of doing what I could for Max as his father. I was denied the chance to save him.

We are grateful to the Coroner for the time she took to consider all of the evidence and the dignity with which she treated Max. My family and I welcome her findings which were very difficult to hear but show how terribly Max was failed. Our whole family loves Max and we deeply miss him. He is always in our daily thoughts and there isn’t a day that goes by when we don’t think about him.

Max would have been really pleased that the Coroner recorded his sex as male. His identity meant a lot to him and he would be proud to know he contributed to the promotion of trans rights in death.”

Alice Wood, Solicitor at Farleys Solicitors, said:

This is a very tragic death which could have been avoided. There ought to have been a multi-agency approach to Max’s care and also consideration of inpatient treatment. It is an important finding of the Coroner that the care provided by CAMHS contributed to Max’s death and shows the importance of families being involved in the care provided. This inquest also highlights the importance of Legal Aid funding for families in inquests, to allow for meaningful participation for families and to ensure learning and accountability.

Ciara Bartlam, Barrister at Garden Court North Chambers, said: “The Coroner’s decision to record Max’s sex differently on his death certificate from his birth certificate is ground-breaking and a small comfort to Max’s father and his family in these tragic circumstances. The Coroner was clear that Max’s dad was not given the information he needed to keep Max safe – sadly, concepts of capacity and confidentiality often seem to be barriers to safeguarding 16 and 17 year olds.”

Max’s father is represented by INQUEST Lawyers Group members Alice Wood of Farleys Solicitors and Ciara Bartlam of Garden Court North Chambers.

The family is supported by INQUEST Caseworker Caroline Finney.