Locket Ure-Williams
Age 1528 Sep 2021
Tongham, Surrey (United Kingdom)
Suicide
Locket died by suicide. An inquest found that "failings by Surrey & Borders Partnership NHS Trust & CAMHS contributed to the death of a vulnerable teenager".
Locket Williams, described by their family as ‘a lovely person with a huge character,’ was just 15 years old when they tragically died after [suicide method redacted] in September 2021.
At an inquest into their death, which considered whether their risk of suicide was properly recognised, monitored and addressed by relevant state agencies, Senior Coroner Richard Travers concluded that there were a number of key failures in Locket’s mental health care and treatment. These contributed to Locket’s death.
The Senior Coroner found that Locket had a known, evidenced, and long history of self-harm and suicidal ideation. This included three past suicide attempts within seven months. Locket’s high risk of suicide was underestimated by clinicians, and Locket did not receive the treatment they needed. In particular:
There was a delay in diagnosing Locket and in recognising their need for treatment;
There was a failure to assess the likely impact of a wait for treatment and whether Locket could be kept safe whilst waiting eight months for Cognitive Behavioural Therapy (‘CBT’);
There was a failure to commence treatment in a timely manner, given the severity of Locket’s mental health conditions and ongoing high risk of suicide;
There was a failure to provide Locket with any continuity of care between clinicians;
There was a lack of clarity as to who was responsible for Locket and which team was responsible for advocating for Locket and their needs;
There was an underestimation of Locket’s level of risk by clinicians, which took a “wholly insufficient account of their longitudinal risk;” and
There was a significant delay in providing Locket with CBT, which Locket was ready and willing to engage in.
The Senior Coroner concluded that these failings contributed to their death by suicide.
Whilst the public bodies contested the application of Article 2 of the European Convention on Human Rights at the conclusion of the inquest, the Senior Coroner agreed with the family that it remained engaged and that the Trust was aware of a “real and immediate” risk to Locket’s life, and that this was a risk for which the Trust had assumed responsibility.
Locket’s older sister said this about them:
"Even though Locket struggled to find happiness in their world, they constantly brought happiness to others. On their darkest days, they still had so much love for the people they cared about, which is why we all have different but powerful memories to hold on to."
https://www.getsurrey.co.uk/news/surrey-news/teenage-girl-struck-by-least-21900453
https://www.dailyrecord.co.uk/news/girl-15-struck-by-least-25254096
https://www.pressreader.com/uk/aldershot-news-mail/20211027/281547999101609
https://www.inquest.org.uk/locket-ure-williams-inquest
https://x.com/DadTrans/status/1816598436881346647
