Lack of mental-health care contributed to Brighton trans teen’s death, coroner rules

Axel Matters

Neglect and a lack of mental-health support contributed to the death of transgender Brighton teenager, a coroner has ruled. 

Axel Matters was found dead at a flat in the city on 23 April 2021, just months after his 18th birthday. Police said he had been there for a number of days. 

Matters had been placed in 24-hour supported accommodation between June 2019 and January 2021, after being deemed an “exceptionally vulnerable person”.

Despite this knowledge, in February 2021 he was placed in emergency unsupported accommodation, having never previously lived alone.

Penelope Schofield, the senior coroner for West Sussex, Brighton and Hove, ruled that neglect contributed to Matters’ death. She said that mental-health services failed to arrange a suitable discharge and care plan after his unplanned discharge from hospital on 22 February, 2021. 

On that same date, the adult social care services failed to arrange a capacity assessment, prompting Schofield to say that there was “lack of consideration by all agencies involved”.

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Matters’ lead practitioner from the mental-health service failed to engage with him after his discharge, and, on 6 April, following a decline in his mental health, adult social care staff failed to arrange a full risk assessment and mental-health review.

Delivering a narrative conclusion, the coroner said there was a lack of support provided by the Adult Assessment and Treatment Service in Crawley pending Matters’ transfer to Adult Assessment and Treatment Service in Brighton.

Schofield will be making a Regulation 28 Prevention of Future Deaths Report, demanding action be taken to prevent further deaths, in relation to the failings in care provided by Child and Adolescent Mental Health Services. 

‘We hope lessons can be learned’

Angela and Melvill Price, Matter’s mother and stepfather, said they agreed with the coroner’s conclusion, but this “should never have happened in the first place”, they added.

“We hope that no other family has to go through what we have been through.” 

Hayley Chapman, a solicitor at Hodge Jones & Allen, who acted for the family, said: “The coroner’s finding that his death was contributed to by neglect rightly reflects how badly Axel was let down. We hope that lessons can be learned from his tragic death.”

Although Axel took his own life, the coroner found it could not be determined whether he intended to do so, the law firm said in a written statement.

The verdict follows an inquest into the death of a 20-year-old trans woman being expected to examine the impact of the lengthy waiting lists she experienced while looking for gender-affirming care.

Suicide is preventable. Readers who are affected by the issues raised in this story are encouraged to contact Samaritans on 116 123 (, or Mind on 0300 123 3393 ( Readers in America can contact the Suicide and Crisis Lifeline by texting 988 (