Coroner rules neglect and multi-agency failings caused death of vulnerable trans teenager


The Senior Coroner for West Sussex, Brighton and Hove has found that neglect and multi-agency Social Services and mental health care failings contributed to the death of 18-year-old Axel Matters, a young trans person whose birth name was Yasmin Price, in April 2021.

Axel took his own life in a flat in Surrey Street in Brighton, shortly after his 18th birthday. The Coroner found it could not be determined if he intended to do so. Axel was known by services to be exceptionally vulnerable, estranged from family and friends, and at risk of potential death from misadventure by severe self-harm or from suicide. Following an unplanned discharge from Langley Green Hospital to police custody on 22 February, he was placed in emergency unsupported accommodation in Brighton, where he stayed for two months prior to his death. He had never previously lived alone. Contrary to his Care Act 2014 care and support plan, an assessment of his capacity to make decisions in relation to his care and support and ability to live alone was never completed.

Following an Article 2 ECHR inquest held between 25 September and 10 October, the Senior Coroner concluded as follows:

On 22nd February 2021 Axel had a unplanned discharged from Hospital, following his arrest by Police, at a time when he was showing signs of a decline in his mental health. The agencies failed him in that:-

  1. The Mental Health services failed to arrange a coherent planned discharge on 22nd February 2021 and provide a clear risk, crisis and care plan on discharge.
  2. Adult Social care failed to arrange a capacity assessment upon his discharge on 22nd February 2021 or any time thereafter.
  3. There was lack of consideration by all agencies involved with Axel as to whether the accommodation provided to him was suitable for a young person, whose capacity fluctuated when in crisis, and who in those circumstances became unsafe to live alone.
  4. Axel’s lead Practitioner failed to assertively engage with Axel after discharge and meet with him in person. She was therefore not able to assess his ongoing risk or recognise his mental health deterioration.
  5. On 6th April 2021 following an obvious decline in Axel’s mental health presentation there was a failure by Adult Social care staff to arrange a full risk assessment and mental health review.
  6. There was a lack of support and active engagement for Axel provided by the Adult Assessment and Treatment Service in Crawley pending his transfer to Adult Assessment and Treatment Service in Brighton.
  7. Axel’s death was contributed to by neglect.

The Coroner is to hand down a full ruling on the legal elements of the case, including the application of Article 2 ECHR, in due course.

Axel’s family was represented by James Robottom, instructed by Hayley Chapman of Hodge Jones & Allen.

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The case has been reported by the BBC and covered in South East Today at 10:15.