Meldreth teenager who ended own life ‘slipped through the cracks’ of mental health system, inquest concludes

PUBLISHED: 19:39 14 June 2016 | UPDATED: 14:02 15 June 2016

An inquest has concluded that Edward Mallen committed suicide after slipping through the cracks of the mental health system.

An inquest has concluded that Edward Mallen committed suicide after slipping through the cracks of the mental health system.


A Meldreth teenager who had everything to live for ‘slipped through the cracks’ of the mental health system, an inquest concluded today.

Edward Mallen, an A* student who had received an offer to study at Cambridge University, descended into a deep depression in the months leading up to his suicide when he died in front of a train on February 9 last year.

The 18-year-old’s parents had encouraged him in the previous month to see family GP Jens Richter, who prescribed him with anti-depressants. Ed told Dr Richter he had been self harming and had suicidal thoughts, so the doctor referred him to Cambridge and Peterborough NHS Foundation Trust.

The Coroners’ Court at Huntingdon Town Hall heard how his school work was suffering and he wasn’t socialising.

Edward was then seen by Duncan Maxwell, a liaison psychiatric practitioner, who did not think he was at serious risk of suicide. Although he wanted to talk to parents Steve and Suzanne Mallen, he was assured that Edward would talk to them, and he gave him some websites to look up on a piece of paper.

However, there was no further communication from the foundation trust – a letter was sent offering an appointment in a month’s time, but it was incorrectly addressed.

During the inquest, the court heard from Dr Chess Denman, medical director of the foundation trust, who said that ‘he slipped through the cracks’. If someone was in his situation again they would be seen by the locality team, and would be given proper leaflets, not hand-written notes, and would not have left without having another appointment arranged.

Ed’s parents became increasingly concerned and, on February 6, their son visited a private psychologist called Victoria Morgan. The meeting went well, and she described how eloquently he spoke, and that he didn’t appear agitated – he even spoke of his future plans. Afterwards she described her shock at hearing that he had ended his life.

Ed had seemed more positive after the appointment – on the Saturday before his death, the day after he saw Mrs Morgan, he played XBox games with his brother and went to the pub with his friends. Steve later told the court he now wonders ‘if it was his way of saying goodbye’.

Coroner Belinda Cheney ruled that Ed died of multiple traumatic injuries caused by suicide.

She highlighted the underfunding of mental health services nationally, and failings in the way his case was dealt with – no one told the teenager about the side effects of the anti-depressants he took and he didn’t have one stable contact, which didn’t help his feelings of low self worth. She plans to write a letter to the parties involved.

She concluded: “As Steve Mallen said, Edward ‘slipped through the cracks’. He had everything to live for – at least from the outside. I think the CPFT have learned lessons from his tragic death. It’s every parents’ nightmare and I admire the way Steve has channelled his grief.”

She went on to say how her own son had benefited from Steve’s subsequent work speaking in schools – as part of his campaign work with the charity The MindEd Trust, which he set up in the wake of his son’s death.

Speaking outside the coroner’s office, Steve said: “This has been a long and torturous journey for my family. We are pleased with the findings of the inquest. Many lessons have been learned, and there’s much more we can do - with early intervention, my son would still be here.”

Dr Chess Denman added: “Edward Mallen’s death was a terrible tragedy and the community trust is very sorry that it occurred. Our thoughts are with his family who have had to cope, and will have to continue to cope, with this awful event.

“While there are elements in what occurred that may well not have been foreseeable, there were also things we could have done better.

“The trust has held an internal enquiry and also commissioned an independent report and it is implementing the recommendations of the report and enquiry. We will also act on the coroner’s directions.”


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