An inquest has found that a series of failures by various agencies including police, mental health and social services, possibly contributed to a Croydon boy's suicide.

Samuel Howes, a 17-year-old from Purley, jumped in front of a train on September 2, 2020.

In the three years prior to his death, Samuel had been admitted to A&E over 40 times and had 178 contacts with the police.

Days before his death he was held in police custody while making attempts to self-harm, and hours before he died he called 999 from a friend’s house whilst crying and expressing suicidal thoughts.

"Samuel’s last cry for help went unanswered," said his mum, Suzanne Howes.

On August 30, 2020, Samuel was arrested by British Transport Police (BTP) and held in police custody whilst under the influence of alcohol.

A BTP officer described Samuel banging his head repeatedly and self-harming so badly his clothes were confiscated.

Samuel was left naked on the cell floor.

In his evidence the officer described this behaviour as "attention seeking" and "fairly normal".

In custody, Samuel was supposed to see both a custody nurse and a psychiatric liaison nurse.

Neither saw Samuel.

The psychiatric liaison nurse was specifically told by custody staff that he was "well known and violent" and didn’t need to be seen.

Samuel was released from custody 20 hours later, with no mental health assessment or ongoing safeguarding referral having been completed.

In the evening on September 1, 2020, Samuel was recorded as a missing person by the Metropolitan Police after an incident at his accommodation.

Early the next morning, Samuel contacted the London Ambulance Service (LAS) from his friend’s house whilst crying and expressing suicidal thoughts.

Police officers visited the address but did not find Samuel there.

Samuel’s level of risk as a missing person was classed by the police as "medium" and this assessment was not escalated to high-risk despite his history and vulnerabilities.

There was no active search for Samuel. During the inquest, the police admitted to failings during this final opportunity to save Samuel, accepting the progress made to find Samuel was “zero”.

He died by suicide after being hit by a train in Croydon.

The inquest concluded that his death was possibly contributed to by the following factors:

  1. The inadequate response of mental health and or social care services in relation to Samuel’s dependency on alcohol and the possibility of a rehabilitative placement.
  2. The failure to adequately share risk information by social services and/or mental health services with each other and with the police.
  3. The sharing of risk information by the MPS and/or BTP with partner agencies.
  4. Steps taken by the MPS to seek an assessment of Samuel’s mental health by a Liaison and Diversion practitioner whilst he was in custody on 30 and 31 August 2020.

The youngest of four siblings, his family described him as a “smart, articulate and creative boy who was full of potential”.

Samuel was passionate about playing football and supported Crystal Palace, while he also loved writing and performing music.

Samuel’s mother, Suzanne, said “Losing Samuel has been a crushing heartbreak, traumatic beyond our comprehension. Every day and each new experience that we encounter as a family is impacted by his loss. We are changed forever by his death.

"Samuel needed and deserved to be safeguarded. He was spiralling, frequently in crisis and returned to self-harming. I along with many professionals feared for his life. He said he wouldn’t live to be 18.

"Measures should have been put in place to protect him and provide wrap-around care to manage his safety. Croydon Children’s Services, as his corporate parent, should have led this response.

"The Metropolitan Police and British Transport Police should hang their heads in shame. Samuel was crying out for help in custody and severely self-harming. Multiple police officers labelled him ‘attention seeking’. The culture of casual indifference and lack of accountability of both police forces is shocking.

"Samuel’s last cry for help went unanswered. He called an ambulance for the first ever time stating he was suicidal, hours before his death. A robust police missing person investigation should have been initiated. Instead, he was failed.

"The inquest and its long, chaotic build-up have been brutal and harrowing. Hearing evidence of Samuel’s pain, unanswered cries for help and the many missed opportunities to save him will haunt us forever.”

When life is difficult, the Samaritans is available 365 days, 24/7. Call for free on 116 123, email, or visit