In a heart-wrenching case that highlights the shortcomings of mental health and social care services, the West Sussex Coroner, Penelope Schofield, has ruled that the death of Axel Matters, an 18-year-old trans man, was “contributed to by neglect.” Axel’s passing in April 2021 in Brighton sheds light on the pressing need for improved care for vulnerable individuals within the LGBTQ+ community.
During the inquest, it became evident that Axel, who was at “exceptional risk” of self-harm, did not receive the necessary support he desperately needed. Mental health services failed to provide a clear risk assessment, crisis plan, and care plan upon his discharge from the hospital, leaving him without a crucial safety net during a vulnerable period of his life.
Moreover, adult social care services failed to conduct an assessment at the time of his discharge or afterward, neglecting to ensure his well-being. It was clear that Axel should not have been living alone, but agencies failed to assess whether the accommodation provided to him was suitable for someone facing such challenges.
Axel’s lead practitioner failed to engage with him post-discharge, missing vital opportunities to evaluate his ongoing risk. Regrettably, this lack of oversight continued as Axel’s mental health deteriorated, with social care staff failing to recognize his deterioration and assess his ongoing risk effectively. There was also a concerning lack of engagement while transferring his care between services in Crawley and Brighton.
Tragically, Axel Matters passed away in a flat in Surrey Street, Brighton, shortly after celebrating his 18th birthday. His story serves as a stark reminder of the critical need for improved mental health and social care services, especially for vulnerable individuals within the LGBTQ+ community. It is a call to action for authorities to prioritize the well-being and safety of those who are at exceptional risk, ensuring they receive the care and support they so desperately require.