Axel Matters: Neglect contributed to trans teen's death - coroner

Axel Matters died shortly after his 18th birthday

The death of a trans man who took his own life had been "contributed to by neglect" by mental health and social care services, a coroner has ruled.

Axel Matters, 18, who died in April 2021 in Brighton, was at "exceptional risk" of self harm, his inquest heard.

The West Sussex Coroner, Penelope Schofield, concluded mental health services failed to provide a care plan after he was discharged from hospital.

She said agencies had failed to assess whether he was safe living on his own.

Delivering a narrative conclusion, Ms Schofield said Axel had an unplanned discharge from hospital in February 2021 following his arrest by police.

The coroner ruled agencies had failed him, in that:

• Mental health services failed to provide a clear risk, crisis and care plan on discharge

• Adult social care failed to provide an assessment either at the time of discharge, or thereafter

• Agencies did not consider whether accommodation provided to Axel was suitable for someone who was unsafe to live alone

• Axel's lead practitioner did not engage with him after his discharge, or meet with him in person. "She was there not able to assess his ongoing risk", Ms Schofield said

• Following a decline in Axel's mental health on 6 April 2021 social care staff failed to assess his ongoing risk or recognise his deterioration

• There was a lack of engagement with Axel while his care was transferred between services in Crawley and Brighton

Axel died in a flat in Surrey Street in Brighton, shortly after his 18th birthday.

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