A disabled boy who tragically fell from a cliff during lockdown had received inadequate support from authorities before his death, a coroner has found.

Sammy Alban-Stanley, who lived in Ramsgate, had repeatedly tried to harm himself during "dangerous and life-threatening" behavioural episodes caused by rare condition Prada Willi Syndrome.

But despite desperate pleas from his mother for extra support from Kent County Council, and children and adolescent mental health services (CAMHS), she was told he "did not meet the Children with Disabilities criteria". Instead, the 13-year-old was assessed as at low risk of self harm or suicide.

Yet on the morning of April 22 last year, after a behavioural episode at home, unknown to his family he left his house and climbed over the railings on Ramsgate clifftop.

Despite efforts to help from passers-by, Sammy - described as an absolute joy and pleasure, and adored by his family and the community - fell backwards, sustaining head injuries from which he died four days later.

During a nine-day inquest, Sammy's mother Patricia said he was a beautiful, gentle soul, but that during PWS episodes - described by a doctor as "predictably unpredictable" - his behaviour became unmanageable and put his life at risk.

He would lose control, be violent towards her, self-harm and attempt to take his life.

He had previously tried to drown himself in the sea, attempt to jump from Ramsgate harbour and run into moving traffic on a motorway, while his mother and others - sometimes his siblings or bystanders - would try to restrain him.

Mrs Alban-Stanley said he often didn't remember them happening afterwards, which upset and terrified Sammy, who loved playing the piano, horse-riding and carpentry.

There were more than 29 police contacts and at least 13 referrals made by the police to KCC. On two occasions he was detained under Section 136 of the Mental Health Act.

Mrs Alban-Stanley said she had been struggling to manage the episodes, particularly as he grew bigger, and was in desperate need of support at home, outside of school hours.

But during the inquest it was heard that the Children with Disabilities (CWD) team at KCC would not even assess him or get involved, and that CAMHS, run by North East London Foundation Trust (Nelft), would only offer medication.

In July 2019, Mrs Alban-Stanley was finally given two extra hours of help at home a day by KCC, which took six months to even start.

Sammy had also spent a year out of school after the family relocated from Hampshire to Kent in 2018, at which point KCC removed his Education Health and Care Plan - a legal document for children with special educational needs - insisting he should be in mainstream school.

After the family pushed for an SEN school, he was eventually able to get a place at Laleham Gap in Ramsgate, where he was thriving.

But from October 2019 onwards, his behavioural episodes became more frequent. He threatened to kill himself with a knife, swallowed a needle twice, was seen biting his arm at school and tried to jump from a window.

By March 2020, Mrs Alban-Stanley was having to call the police almost every day. With lockdown looming, the school were concerned about the extra support he would need when it was learned he would have to shield at home, due to being more at risk to Covid because of his PWS.

'His mother did her utmost to keep him and his family safe but needed help from police'

Mrs Alban-Stanley said the family was at crisis point and they were not being given the support needed to keep her son safe.

During her conclusion, coroner Catherine Wood said the social workers assigned to Sammy were in unfamiliar territory and were not assisted by the CWD team at KCC who tried to "shift the focus" to CAMHS.

"KCC were fully aware that Sammy during his behavioural episodes was known to put his life at risk," she said.

"The risks were predictably unpredictable and therefore could not be anticipated, although Mrs Alban-Stanley considered the most risky time to be before and after school in a busy household.

"His mother did her utmost to keep him and his family safe but needed help from police to manage some of the episodes."

Ms Wood said in December 2019 and then a month later, Child in Need meetings were held by the local authority to discuss the situation and in both instances CAMHS was invited but did not attend.

During the hearing, Mrs Alban-Stanley said Sammy, who also had autism and anxiety, fell through the cracks of the system.

"He was deemed not disabled enough to be awarded a proper level of care yet he was too disabled for me and my daughters to manage at home," she said.

Summing up, Ms Wood said there was a clear failure in what was provided by KCC to Sammy’s family to help with his care.

She said they failed to provide help out of school and there was a failure by the social services team to recognise an increased risk to Sammy. She added that “it was possible if not probable that a failure to provide extra support contributed to Sammy’s death".

'Sammy was exceptional, a dearly loved son and brother'

Ms Wood noted that the CWD team at KCC had chosen not even to assess Sammy as it considered on paper that he did not meet the criteria for their support. As a consequence, Sammy was seen by social workers unfamiliar with the services that could have been provided.

The coroner was also critical of the mental health service at Nelft, saying that had information been shared in a timely manner it is possible that more support could have been offered to Sammy and his family - which may ultimately have made a difference to his high-risk episodes and his death.

She gave a narrative verdict, concluding that Sammy died as a consequence of injuries sustained during an episode of high-risk behaviour related to PWS on a background of inadequate support from the local authority and mental health services.

Matt Dunkley, corporate director of children, young people and education at KCC, said the authority wholly accepts the coroner's findings and improvements have been made within the service.

"We are grateful for her acknowledgment of our reflective analysis outlining the valuable lessons learned and subsequent interventions and improvements put in place within our children’s services," he said.

"We take our responsibility for Kent’s children extremely seriously and will continue to strive to deliver the very best care and support possible for them and their families."

Nelft says it has taken a number of actions to improve its services following Sammy's death.

"The Trust is continuously reviewing the quality of care and treatment provided to patients and as an organisation we will reflect on the findings with a view to improving patient care in the future."

Speaking after the hearing, Mrs Alban-Stanley said she believes that a failure to provide the family with adequate support led to Sammy’s death.

"He was exceptional, a dearly loved son and brother," she said.

"With his wonderful sense of humour and happy disposition, we enjoyed a joyful family life.

"We had projects, adventures and a future planned. He had so much yet to give. Sammy bravely faced what society threw at him, persevering to try to overcome challenges arising from his disability.

"We had a very close connection and bond. I learnt so much from him, and I am so proud of him.

"Although I did all I could to cope with Sammy’s episodes, we were in crisis and the very limited support that we were finally awarded simply was not sufficient.

"We were operating at crisis point continually and things continued to escalate after Sammy was unable to attend school during the national lockdown.

"Every incident that Sammy had was life threatening and it was only my attempts to try to keep him safe, using all my energy and reserves, that nothing more serious happened before April 22.

"The authorities were aware of the risks but, in my view, did not take this seriously.

"The coroner has heard evidence of all I did to fight to get the bare minimum in place to keep Sammy safe and yet this was always rejected. I was always told the support I desperately needed for Sammy wasn’t available and I should ask elsewhere. Nobody was willing to help us.

"Not only do I have to endure his loss but also the loss of his future too.

"Whilst he had a great many struggles due to his disability fitting into this world, his soul was gentle and resonated the deepest, most resounding love I have ever known.

"He brought joy and comfort to all who knew him, changed people’s lives for the better, he made my life multi-dimensional and multi-coloured. He made the world a much nicer place."