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The inquest into the suicide of an Ilford teenager has revealed his school tried to help him but were left in the dark by an NHS error.
Following the death of 15-year-old Zain Pervez on June 12, a relative suggested Oaks Park High School in Ilford had not supported him despite knowing he had suicidal thoughts.
However, at Walthamstow Coroner’s Court on Friday November 27, assistant principal Emily De Grove explained school staff contacted him daily after learning about his struggles on March 5.
The school referred him urgently to North East London NHS Foundation Trust (NELFT) for a mental health assessment, which did not take place until three weeks later.
A NELFT psychologist spoke with Zain on April 1 and discharged him, deeming him a “low risk” despite the school’s concerns. Due to an error, the school did not learn this until after his death.
A statement from the family read by coroner Ms Nadia Persaud described Zain as a “sweet and wonderful boy”, who was a “responsible and protective” brother to his three younger siblings.
The statement read: “As Zain grew from a boy into a teenager, we could see the man that he would become: strong, steadfast and assured.
“He was growing into a young man with so much enthusiasm and had made so many plans for the future.
“Zain was and always will be adored by his family and we are so saddened by his death. He will be dearly missed, not just by the family, but by his friends and the community.”
The court heard evidence Zain had been struggling with his mental health since at least October last year and had attempted suicide impulsively that December.
On March 5, a Sunday evening, he told school staff online he was suicidal. They arranged a meeting with his parents the next day and referred him to NELFT’s mental health team.
After becoming concerned he might hurt himself while travelling on his own to and from school, he was also allowed to leave early every day so his mum could pick him up.
Regarding the referral to NELFT, Miss De Grove said: “He was moved up the waiting list because he was so urgent but between March and June, we didn’t get any feedback.
“After his death, we continued to chase and that was when we found out a clinician had met with Zain and it had been decided to close the case because he didn’t feel he needed any help.”
She said if the school was sent a letter about his discharge, as is normal practice, staff would have asked to speak to the clinician “because of how severe his suicidal ideation had been”.
Despite reports from his peers suggesting Zain was bullied, she added the school only learned of one incident after his death, which was “minor”.
The court also heard from Dr Rowena Toki, the NELFT clinical psychologist who spoke with Zain and his mother Syeda via videocall on April 1.
Despite an interpreter for Zain’s mother not being present, Dr Toki chose to go ahead with the assessment, with her consent, because it had been so long since he was referred.
She said: “I was concerned by the length of time it had been since anybody had spoken to Zain. At the start he appeared quiet but quickly relaxed and was able to answer all my questions.
“At the time of my assessment, Zain reported he had no suicidal thoughts and no plans to end his life. He and his mum said his mood had significantly improved since the referral.”
Despite both the school and later his GP referring him to NELFT as a “high risk”, the team deemed him “low risk” and discharged him after he declined therapy.
Coroner Ms Nadia Persaud said: “What I struggle with is the decision to discharge him without perhaps making arrangements to speak to him again, to see if that was just a good moment.
“I’m not clear how you could conclude there was no active risk at that time given his recent history and his age.”
Asked if she would treat young people like Zain differently in future, Dr Toki said: “I will try my best to stay in touch and communicate with external agencies to make sure plans are in place.
“It was just such an unfortunate time (because of lockdown), otherwise we would have been seeing him face to face.”
The court also heard that, after reflecting on his death, the trust will ensure high priority cases like Zain’s “are seen within five days”.
It will also make sure it notifies all referrers when a patient is discharged, explains more about its reasons for discharging and follows up with young people who refuse therapy.
Ms Persaud said: “This inquest is not about blame and no one is on trial, least of all the deceased. I’m not allowed to reach a conclusion that appears to determine criminal liability.
“Having heard evidence from the school, I think they did a lot to try to keep him safe.
“I cannot find that, had the mental health team spoken to him sooner or had they shared the outcome of their assessment with the school, it would have made a difference.”
She said that while it is likely the school would have spoken to the clinician if they had known he was discharged, “it is not possible to say” if this would have led to him being re-referred.
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