Sam MarxAge 17
20 Feb 2017
Dunkeld, Perth and Kinross, Scotland (United Kingdom)
Sam died by suicide at his school.
He was autistic but according to his mum had been thriving since starting there two years earlier. A subsequent review confirmed that the local council had decided not to support him for a third year, and it seems likely that this and the lack of support offered to help him cope with his gender dysphoria were factors in his death.
A transgender teenager took their own life in Perth and Kinross after their cries for help went unheard by local services, The Courier can reveal today. A probe into the circumstances surrounding the tragic death found the support received by the 17-year-old was too often “fragmented, inconsistent and uncoordinated”.
The pupil was found dead shortly after being told by education chiefs that they would not be allowed to attend the New School Butterstone for an extra year. The suicide in February 2017 set in motion a breakdown in the turbulent relationship between Perth and Kinross Council and senior staff at the school, which controversially closed at short notice in November 2018.
The “sensitive and intelligent” teenager had also become frustrated at the lack of progress to address their growing sense of gender dysphoria. The newly-published report said the pupil had been referred for specialised treatment and possible gender re-assignment. But the professionals involved later admitted they would have delayed the referral if they had been aware of the vulnerable teen’s history of self-harm and suicide attempts.
During the review, undertaken on behalf of Perth and Kinross child protection committee, some non-specialist staff spoke about “not feeling confident” when working with young people with gender dysphoria. A total of 17 recommendations were made to improve services in the wake of the tragic death of the pupil, who is known in the report as “Young Person A”, including improved training for staff.
The shock report’s findings include:
- The teenager’s “troubling” narrative was being listened to at the time but was not being properly heard or understood by officials
- Evidence of “silo working” among the more than 14 separate professionals supporting Young Person A
- Huge pressures on local Child and Adolescent Mental Health Services (CAMHS)
- Health staff had “incomplete picture” when referring the pupil for specialised treatment and possible gender re-assignment
- Strained relations between the education service and the family and school
- A lack of governance and oversight, or anyone acting as “named person”.
After Sam's death the relationship between the school and Perth and Kinross Council broke down, and it closed 21 months later. A probe into his death showed a ‘considerable lack of respect’ to his family.
A fresh probe is under way into the sudden death of a teenager at the New School Butterstone.
The apparent suicide in February 2017 set in motion a breakdown in the turbulent relationship between senior school staff and Perth and Kinross Council.
Jim Martin CBE, who released the results of his independent inquiry into the school’s closure this week, confirmed that a “significant case review” into the 17-year-old’s death had now started. But he said the delayed investigation, which began more than three years after the tragedy, “showed a considerable lack of respect” to the student’s family.
Mr Martin’s review found that concerns about child protection – unrelated to the 2017 death – and financial problems had led to the school’s shock closure in November 2018. With just four days’ notice, all 24 students were forced out of the building and 51 staff lost their jobs.
The school’s head Bill Colley has rejected the findings of the review and said he felt “scapegoated” by others involved in the inquiry.
The suicide came just weeks after a former student took their own life, the inquiry heard. Mr Martin said: “The aftermath of this event had a considerable impact on all those connected with the school, particularly those staff who had gone to the young person’s assistance.”
He said the pupil – who has not been identified – had been at Butterstone for two years. “Not long before their suicide, Perth and Kinross Council had written to confirm that they would not support the pupil’s attendance at the school for a third year,” said Mr Martin, stressing that the question of why the young person decided to take their life was not part of his review.
“Now, three-and-a-half years after the young person’s tragic death, I am told the Significant Case Review is now under way. “In my view, and I acknowledge this is also outwith the terms of the review, this delay shows a considerable lack of respect for the young person’s family, and for those members of the school staff who were directly responsible for trying to assist the pupil and to manage the school in the aftermath of this tragic event.”
He said he was grateful to the teenager’s family for supporting the review.
Significant Case Reviews are carried out by child protection committees and evaluated by the Care Inspectorate. The aim is to establish the facts surrounding the case and look at what lessons can be learned. The Care Inspectorate has declined to comment.
After the student’s death, Perth and Kinross Council issued a list of demands to the school. Mr Martin said: “The tone of the letter, while offering condolences, was at best insensitive, took no account of the impact of events on the staff of the school, or the challenges they faced in trying to manage a small school through a traumatic event.”
The review found this had a damaging effect on relationships between the school and the local authority. It led to staff believing council officials were “out to make life as difficult as possible for the school in the hope that it would fail”.
Mr Martin said: “Neither the senior management staff of the school, nor the council officials, come out of this well. “It appears to me that, over the piece, neither was prepared to accept that the other was acting in good faith.”
A Perth and Kinross Council spokesperson said: “The council can confirm that the Child Protection Committee has systems in place to follow national guidance in relation to the conduct of multi-agency case reviews.
“In this case, the appropriate timing for commencing this work has been kept under regular review. An independent reviewer was appointed in January 2020 and it would not be appropriate to comment further while this work is underway.”
The relevant sections of the review are reproduced below:
Chapter 3: February to December 2017
3.1 The overview below is set out in chronological order. It specifically covers critical periods where interactions with, and between, the Relevant Bodies have been evidenced and correlated.
3.2 This period principally covers the time that Head of School A was in post. The Head of Care referred to in this report was in post throughout the period of this Review.
3.3 On 20th February 2017 a student took their own life while attending the School, only weeks after a former student of the school had also taken their own life. The aftermath of this event had a considerable impact on all those connected with the School, particularly those staff who had gone to the young person's assistance.
3.4 The pupil had attended the School for the previous two years. Not long before their suicide, Perth and Kinross Council had written to confirm that they would not support the pupil's attendance at the School for a third year. It is not within the Terms of Reference of this Review to investigate what caused this young person to make the decision they did. Now, three and a half years after the young person's tragic death, I am told that the Significant Case Review is now underway. In my view, and I acknowledge this is also outwith the terms of the Review, this delay shows a considerable lack of respect for the young person's family, and for those members of the school staff who were directly responsible for trying to assist the pupil and to manage the School in the aftermath of this tragic event. I am grateful to the family of this pupil for their support of this Review.
3.5 Following the death, on 22 February 2017, HM Inspectors and the Care Inspectorate visited the School to satisfy themselves about the arrangements within the School for the safeguarding of pupils. Some weaknesses were noted. On 27 February 2017, Scottish Ministers placed 5 conditions on the running of the School in accordance with section 98E(1)(a) of the Education (Scotland) Act 1980 (the 1980 Act). The Conditions referred to: the updating and accessibility of young people's files; a review of all care plans for the School's young people; staff awareness of care plans; and a review and update of school Information and Communications Technology (ICT) policies.
Sam's mum described him as "very grown up" and said he had been thriving at the school.
“...losing a child, it completely knocks the fight from out under you, especially in the way we lost Sam. It takes away all your coping mechanisms.
“It’s completely different. I had never known anyone personally who had done that so I didn’t know how to feel or how I should respond.”
Speaking about Sam, she describes a youngster who was “very grown up”.
She added: “He had struggled in school but once he got to Butterstone, he absolutely thrived – he just found a home.