Inquest into self-inflicted death of 16-year-old Leo Barber finds missed opportunity by NHS mental health services
3 October 2025
Garden Court North’s Camille Warren represented Leo Barber’s family during the four-day inquest in September 2025 at South London Coroner’s Court (pictured). Credit: Glen Berlin / Shutterstock.
An inquest into the self-inflicted death of 16-year-old Leo Barber found that there was missed opportunity by NHS mental heath services to prevent his death on 28 November 2023.
Leo’s family, who was represented by Garden Court North’s Camille Warren, remember him as an inquisitive and highly intelligent teenager, with a quirky sense of humour. He loved programming and computer games and was a deep thinker with a strong social conscience. Leo continues to be loved and missed by his family.
The four-day inquest into Leo’s death, which took place from 15 to 18 September 2025, concluded that there was a missed opportunity by clinicians in failing to conduct a structured risk assessment following an incident the week prior to his death. His Majesty’s Assistant Coroner Edmund Gritt also found that exposure to pro-suicide online material contributed to Leo’s actions to take his life.
Timeline of events
Leo was neurodivergent and struggled to accept his diagnosis of autism spectrum disorder after receiving this aged 14. He had significant mental health issues from a young age and had started refusing to attend school in early 2023. Leo was also struggling with gender dysphoria and wanted to explore hormone therapy. In September 2023, Leo’s private psychiatrist and psychologist made an urgent referral to Bromley Child and Adult Mental Health Services (CAMHS) due to the severity of Leo’s presentation and level of risk of harm to self, which was deemed to be too complex for individual therapy alone. The private psychiatrist assessed that Leo was not safe as an outpatient in early October 2023.
Following Bromley CAMHS’ initial assessment, and Leo disclosing a recent suicide attempt, Leo and his parents were instructed to immediately attend A&E for Leo to be admitted, which they did the same day on 29 September 2023. Upon arrival at A&E, after a long wait, Leo was discharged with an agreed safety plan including Leo’s parents keeping him under constant supervision at home. The Coroner heard evidence that this aspect of the safety plan could only be short-term because of the impact on the family, and the exhausting nature of this responsibility for Leo’s parents. However, in Leo’s case, the safety plan and the expectation of constant supervision at home remained in place until his death, some four weeks later.
Leo’s mental health continued to seriously deteriorate over the following weeks. He was identified as a Child in Need by Bromley Children’s Social Care, and an urgent Community Education and Treatment Review took place on 15 November 2023. Bromley CAMHS and the SLAM crisis response team were providing the most ‘intensive’ level of support that was available at the time, while Leo was living at home with his family. However, Leo’s family remained desperate for more substantial intervention, and raised concerns that there was no support from a psychologist and Leo only met his allocated psychiatrist once.
It was known by the clinicians working with Leo throughout this period that he was socially isolated, rarely leaving his room or engaging in conversation, and that he had been accessing pro-suicide material online. At around 4am on 23 November 2023, Leo left home on his own and without his parents’ knowledge. Leo’s father noticed this immediately and called him, after which Leo returned home within ten minutes. The Coroner heard evidence that, although this was a highly significant risk event, the entry documenting the clinician’s conversation with Leo about it the next day was poorly documented and read badly. Leo’s parents highlighted concerns at the time about this incident, alongside telling the care team that he had been looking at maps online and his mood had dropped considerably. In response, Leo’s parents began locking the house doors overnight. The evidence provided to the Coroner was that no risk assessment was undertaken by the care team following this incident, nor consideration of the practical and legal implications of this heightened safety plan for the family.
There were delays in communicating the outcome of the Community Education and Treatment Review to the family, and Leo tragically never got to see this before his passing. Leo left the house at around 4am on 28 November 2023, similarly to the incident on 23 November 2023. He died shortly afterwards.
The Coroner heard evidence that following Leo’s death, his father managed to access his online Google account, which provided evidence that Leo had been accessing pro-suicide material on a website called Sanctioned Suicide. The Coroner concluded that Leo’s exposure to this website probably reinforced his decision making, and that a Prevention of Future Deaths report would be issued to Google addressing this issue.
The Coroner concluded on the Record of Inquest that:
1) Leo intended to end his life as a result of a severe clinical deterioration in his mental state over the previous months;
2) Leo had been under the care of crisis mental health services and there was a missed opportunity to prevent his death when 5 days previously he had similarly let himself out of the house at the same hour. That incident was not subject to a structured risk assessment by clinicians; had it been so then Leo would probably not have died when he did;
3) Leo’s actions were contributed to by his exposure to a website forum called Sanctioned Suicide on which individuals exchange information as to methods of suicide.
Leo’s family said: “Leo’s parents, Jo and Chris Barber would like to thank INQUEST, our barrister Camille Warren, our solicitors Alice See and Navjot Kahlon for their help and support after losing our beloved son. The Inquest and the build-up to it was harrowing and stressful and we could not imagine having to go through that process without professional representation as indeed many families are forced to. We are also grateful to the Coroner, Mr Gritt who we felt handled proceedings professionally, fairly and compassionately. In Leo’s memory, we intend to help other families avoid having to go through the heart-ache we now have to live with every day.”
The family were represented by Garden Court North’s Camille Warren, instructed by Alice See and Navjot Kahlon of GT Stewart Solicitors.
Other Interested Persons represented included Oxleas NHS Foundation Trust; South London and Maudsley NHS Foundation Trust; and London Borough of Bromley Children’s Social Care.
Journalists should refer to the Samaritans Media Guidelines for reporting suicide and self-harm and guidance for reporting on inquests.
Additional media
London Evening Standard – Family’s tribute to ‘bright, sensitive, funny and loving’ boy, 16, who died on railway in Bromley
For further information, please contact Alex Blair, Communications Manager at Garden Court North Chambers: ablair@gcnchambers.co.uk
