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Missed opportunities to intervene before 16 year old takes own life

03 Aug 2022

Factual background

On 1 May 2021 Marcella Walton was killed after being hit by a train at the Sharpenhurst foot crossing, near Horsham, West Sussex.

Marcella Barbara Mary Walton was born on 18 December 2004 to Rachel Anne Waterworth and Mark Walton. After the breakup of her parents’ marriage Marcella lived in Boston with her mother and did not see her father for a number for years until her mother’s death in June 2019.

In February 2020 Marcella went to live with her father along with her sister (then aged 13). She had been well known to children mental health services in Lincolnshire and had a history of self-harming. Mr Walton was not informed of this.

On 23 March 2021 Marcella’s school pastor telephoned Mr Walton and informed him that Marcella had expressed suicidal ideations, and recommended that he take her to accident and emergency as a crisis admission which Mr Walton did. After a telephone call with a CAMHS (Children & Adolescent Mental Health Services), part of Sussex Partnership NHS Trust, mental health nurse, she was discharged from accident and emergency.

A call was arranged with a CAMHS Family and Systemic Psychotherapist for 25 March 2021. Suicidal thoughts were expressed by Marcella. Her case was discussed at a MDT meeting on 29 March 2021 and she was offered an initial assessment on 14 May 2021. Marcella was to be put on the “Red Duty List” which would have resulted in her receiving phone calls each week to check on her well-being. This was not done and no record of the MDT discussion was recorded.

The school pastor remained concerned. She notified Marcella’s social worker and CAMHS on 26 April 2021 that she was concerned that Marcella might not make the appointment on 14 May 2021 and that her state of mind was going rapidly downhill. CAMHS informed the pastor that they did not have capacity to bring the appointment forward.

Marcella stepped in front of a train on 1 May 2021 and was instantly killed.

A Serious incident report prepared by Sussex Partnership NHS Trust found the following Care or Service Delivery Problems:

  1. “complicated triage/referral process
  2. The risk management policy was not fully adhered to
  3. No multi-disciplinary discussion recorded
  4. No “Red List” check in by duty
  5. No collateral history sought from previously Children’s Service and CAMHS
  6. No consideration for escalation to either face to face assessment of risk or involvement of Home Treatment Team.
  7. Clinical discussions not recorded on Carenotes (Clinical recording system).
  8. New staff are not getting a full and comprehensive induction remotely.”


Marcella Walton’s case is one of six current cases involving suspected suicide by teenagers in West Sussex. All are being handled by Senior Coroner Penelope Scholefield

Marcella Walton’s inquest was held over 7 – 8 June 2022. Ms Scholefield found that there had been an arguable breach of Marcella’s Article 2 rights (right to life) under the European Convention of Human Rights.
The Coroner further ruled that she found the testimonies of the school pastor to be more reliable than the CAMHS employees, and that there was a missed opportunity for the mental health team on 26 April 2021 to assess Marcella just five days before she took her own life. The Coroner noted that Marcella’s suicidal ideation had been picked up in her two assessments with CAMHS, but that her suicidal intent may have been missed by them.

Ben Davey (Senior Chartered Legal Executive, Dean Wilson Solicitors) who acted for the family said “This is a tragic case that has had devastating consequences for a family that has already experienced recent bereavement. We welcome the conclusion of the Coroner who has said that Marcella’s Right to Life may have been breached, and there were missed opportunities to intervene. This is one of a number of similar cases in West Sussex involving teenage suicide, and it should be a national scandal that our young people are being failed so badly.”

The Dean Wilson Solicitors team are often instructed in similar matters and can be contacted on 01273 249200. They acted in this matter under a no win no fee style agreement. Please contact us today if you would like to speak with our team.

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