A Measure What Matters investigation into the suicide of neurodivergent children failed by the SEND system — and a system that answered their deaths with no learning, no accountability, and, as of today, no recourse.
Content warning: This report contains detailed accounts of child suicide, suicidal ideation, and self-harm. It has been prepared with regard to guidance on the responsible reporting of suicide issued by Samaritans and Papyrus UK. If you are affected by any of the issues raised in this report, support is available:
Samaritans: call or text 116 123 (free, 24 hours a day, every day of the year) Papyrus HOPELINE247 (for young people and anyone concerned about a young person): call 0800 068 4141, text ‘HOPE’ to 88247, or email pat@papyrus-uk.org
This thematic review draws on evidence of the reported educational experiences of 35 neurodivergent children and young people whose deaths, recorded between 2020 and 2024, were preceded by circumstances showing indicators of failures in education provision. 25 of these are examined, in detail, in this report — children and young people whose deaths were examined through Local Child Safeguarding Practice Reviews, Inquest findings, Prevention of Future Deaths reports, and testimony from families.
Children are anonymised.
Where quotations are included, they are drawn directly from the relevant official document or, where no statutory document exists, from family testimony or published inquest reporting.
These cases were identified because published documentation contained recognisable indicators of educational failure. They are not the totality of such cases — they represent what is visible in the public record. As this report has already established, the review architecture governing these deaths has not been designed to specifically surface educational failure as a finding- meaning that in many cases, such failures, where present, may not appear in published documentation at all. The true number of children whose deaths were preceded by the failures described here is therefore unknown. It is likely to be significantly higher.
These are not outliers. They are a pattern.
What follows is what that pattern looks like — in practice, for 25 children, in their own words, through their experiences, their families’ words, coroners’ words, and in the words and findings of the statutory bodies if required to examine their deaths.
The failure begins before the crisis — almost always in school.
In case after case, many of the earliest warning signs are educational. A child falling behind. A child who cannot manage the noise, the transitions, the unpredictability of a mainstream classroom. A child whose behaviour is deteriorating, whose attendance is collapsing, whose distress is being read as defiance. What these children had in common — in almost every case — was a neurodivergent profile where the educational impacts of their profile was either unrecognised, unassessed, or responded to with discipline rather than support.
Child W was diagnosed with severe combined ADHD at the age of eight. His mother recalls raising concerns about his needs since he was two years old. When he started secondary school, she attended a SEND meeting to ensure the school understood him before he arrived. His mother sought an EHCP when he was in Year 7 but was told his needs were not severe enough to qualify. Experiencing severe bullying, serious episodes of self-harm and multiple attempts on his life, he was referred to CAMHS twice, discharged twice, the second time just months before his death. His mother reports the consultant managing his ADHD had been excluded from professional meetings about his educational provision. Despite two school moves, a declined request for alternative provision and a period without education, he died aged fifteen without ever having received a statutory assessment of his special educational needs.
Child G’s school believed, incorrectly, that they were required to spend £6,000 of their own funds on a child’s needs before they could even apply for a statutory assessment.
The Coroner identified this misunderstanding as a direct barrier to early intervention, noting that “educational establishments were misguided about the criteria for applying for an EHCP”, and cited it as a contributor to avoidable suicidality. It is a myth. It has no basis in law, in the SEND Code of Practice, or in any guidance issued by the Department for Education. It is, however, widespread — and it persists.
The detailed 81-page Inquest Report issued by HM Senior Coroner lays bare the comprehensive and prolonged failure of the EHCP process in the relevant local authority, and the role of those failings in the subsequent, preventable suicide of a child. The Coroner was explicit in his findings: “Even when the EHCP was issued, the support and protection which it ought to have secured fell short because the plan, as originally drafted and as amended after review, did not properly convey her needs in relation to her mental health and her risk of suicide. This failure resulted in [the educational institution] being materially underinformed.”
Child S waited ten years for an autism diagnosis, despite presenting with specific traits recognised by school staff from primary school — staff who were surprised when his referral for assessment was not accepted. His review records: “His neurodiversity* [*Note: This is the wording as appears in the Safeguarding Review Documentation] appeared evident from a young age but it took ten years to assess him for ASD. He found it hard to accept the diagnosis as a teenager, he hated to be seen as different. He wanted to be accepted and just like other children.”
He had no EHCP throughout secondary school. As his mental health deteriorated and he was no longer able to attend school, the school refused to provide remote learning. His parents believe that falling further behind in his studies, at a point when he was already in acute distress, was a significant contributor to his deterioration. They also believe the decade-long delay to diagnosis cost him the opportunity to understand himself and come to terms with his difference. He was sixteen when he died.
Child N’s family spent three years fighting for an autism diagnosis after an initial assessment recorded as inconclusive — a finding the family strongly contested. Despite a known ADHD diagnosis, rapidly escalating behavioural issues at school, significant social difficulties and self-harm (including specific incidents at school) there is no evidence of specialist SEND intervention. Evidence at his inquest heard how he struggled with his emotions, was socially isolated, and had very few friends at school. The Coroner observed that it is “impossible to say if [Child N] had received the ASD diagnosis earlier, what support he may have received” — and how that support may have helped him.
His autism diagnosis was finally made and issued a month after his death. He was twelve years old.
Child H’s secondary school applied for an EHCP and was refused assessment by the local authority. The refusal came at a point when Child H had already been detained under the Mental Health Act. Her mother told the inquest: “This was odd given that [Child H] at this point had been detained under section in hospital.” The decision was only reversed after the family appealed. When the EHCP was eventually produced, her mother told the court, “little of it was delivered.”
Child E’s autism was not formally diagnosed until the months before her death. Her review records: “The lack of diagnosis and support from an early age meant that the way she would have experienced the world was not understood by either herself or others. This is especially relevant in terms of the adjustments that could have been made in education.” Her parents had suspected autism for years. Their concerns, the review records, “were not heard by professionals.”
Child I was refused assessment by a multi-agency panel in January 2024, on the grounds of insufficient evidence — despite multiple exclusions, years of severely disrupted education, and prolonged absences from school. His family described “major failings” in his not being in school and his learning needs not being understood in a timely manner. The review found that “opportunities to assess Child I’s educational needs earlier in his life were missed and therefore he did not receive an education that could meet his educational, social, and emotional needs.” It records “drift and delay” in assessing those needs, with evidenced impact on him and his family.
His family circumstances were undoubtedly complex — but education, which should have been a stabilising factor, instead became another source of trauma through unmet special educational need. The refusal to assess his special educational needs was only overturned following challenge resulting in delay at a point of evident crisis. A statutory assessment was initiated in February 2024. He died two months later — at which point, his review records, “all mainstream school doors were shut” to him.
His family noted that he had thrived in his final education provision after years of disrupted education. It was, they said, “too little, too late.”
When needs are not identified, the system’s response is almost always the same: punishment.
Across these cases, what follows identification failure is often predictable; A child whose unmet needs generate behaviour the school cannot manage.
A school that reaches for sanctions — suspensions, exclusions, isolation rooms — rather than addressing the prior question the law requires: is this behaviour an indicator of unmet special educational need?
That question has a legal answer. The SEND Code of Practice is explicit. The Equality Act imposes a duty to make reasonable adjustments. The legal frameworks exists.
But it also must be acknowledged that in many of these cases, evidence suggest schools had already attempted to access support — and been denied. Requests for statutory assessment, declined. Schools left with no alternative mechanism, no specialist support and no recourse.
Independent testimony Measure what Matters has gathered from teachers working within this same system confirms what these cases show: that internal sanctions, suspensions and exclusions are frequently being used as a direct consequence of schools having no other means of managing unmet SEND. The behaviour is treated as the problem. In many instances, schools know the need underneath it has not been addressed — because the system that was supposed to address it has already said no.
Child T accumulated six punishments in four days in the week before he died — often for not paying attention and for answering back, both recognised presentations of his ADHD, the diagnosis he had carried since the age of nine. From December 2022, staff and his parents had noticed a marked change in his behaviour: more behaviour points, more detentions, repeated exclusions from lessons. In January, his mother asked the school to put in support from the SEN team — she felt he had received none since joining the school, despite his difficulties — specifically to try to reduce the class exclusions and detentions. A case worker was assigned in April.
He died the following month. He was fifteen.
Child V was autistic and had an EHCP. Her parents report how the mainstream school she attended did not adhere to the provisions set out within it — a reminder that a plan on paper is only as meaningful as the duty to enforce it. Her EHCP extensively detailed her social communication difficulties, her risk of isolation and vulnerability, and the specific provisions required to support these — support her parents believe to have been largely undelivered, despite evident escalation. She was placed in isolation on repeated occasions, and according to her parents, often in response to incidents where she herself had been targeted by bullies. She told CAMHS that she was suicidal. She was removed from the waiting list on the basis that she was not considered high-risk enough.
She was thirteen when she died.
Child F was permanently excluded from college three days before he died. His mother describes how she had raised the issue of an EHCP a number of times and had requested input from an educational psychologist on many occasions. She was repeatedly told it was not needed or would take too long — and by the time things really unravelled, it was too late.
The college, in evidence at the inquest, acknowledged that it had focused on “disciplinary rather than supportive approaches” despite being aware of his ADHD and dyslexia diagnoses. The Prevention of Future Deaths report expressed concerns about the lack of knowledge and communication by the college about his needs and recognised this as a contributory factor in his death.
He was seventeen, and died without any statutory assessment of his educational needs having taken place.
The Safeguarding Practice Review for Child D describes how endured 45.5 days of exclusion across 22 separate periods. His literacy was assessed by school as approximately five years behind his peers, yet his needs had been managed through Early Help rather than statutory assessment. His father told the review: “He much rather wanted to be thought of as a funny, naughty boy than a thick boy.” He wrote a suicide note in which he begged to be permanently excluded. To be allowed to stop going to school.
He was thirteen when he died.
Child A received fifteen school suspensions in ten months. His mother’s evidence during the safeguarding review told how she felt the school “saw him as a naughty boy” and did not provide the help and support he needed. The review identifies a failure to recognise how his neurodiversity and cumulative experience of educational failure intersected to increase his risk.
He was sixteen.
Child M was placed in a mainstream school that the Coroner found lacked the facilities and expertise to meet his complex needs. Records were not shared between his previous special school and his new mainstream placement. The Coroner described it as “astonishing” that a child with his level of need could transfer between schools without records being exchanged. That wrongful placement, the Coroner concluded, directly contributed to his death.
He was fourteen.
Child U’s review records that she found high school to be “overwhelming in terms of sensory overload” — the noise, the light, the process of lining up for lessons. For a child whose nervous system cannot filter the sounds, sights and smells of a crowded corridor the way others can, a mainstream school is not a neutral environment. It is described as an endurance test, every day, with no acknowledged end point. Despite a secondary school that identified the need for an EHCP and secured one, the multi-agency response throughout remained “largely reactive and not informed by a risk aware response to what was known of [Child U] as an autistic child.” Her primary school had not reviewed her behaviours or learning at all.
Child J struggled from the point of transition to secondary school, feeling, as his review records, like “the naughty kid” — isolated, misunderstood, disengaged. His EHCP annual review made reference to a possible autism spectrum condition, despite there being no formal diagnosis. The review records that “the only external agency invited to participate in the annual review of the EHCP was the careers officer.”
Where a child’s needs are not evident through dysregulated behaviour, they are evident through withdrawal. Where this is not recognised as a symptom of escalating crisis relating to their special educational needs, the response can again be punitive:
“[Child K] ended up changing secondary schools three times. [she was bullied in all three schools]. They threatened me with court if she wasn’t back in school. So I said to them, we’re going into each school and ending up with the same problems. We need the support in place to help [Child K] that obviously wasn’t put in place. This is when she kind of tipped over the edge.”
Families with neurodivergent young people are expressing serious concerns about the punitive approach being frequently deployed in response to what is described as Emotionally Based School Avoidance.
This finding is supported across these reviews, where prolonged gaps in education are a recurring indicator in circumstances preceding the deaths of these children — whether through persistent absence associated with EBSNA, or through repeated suspensions and exclusions.
When placements break down, children are left with nothing.
The legal duty to provide suitable, full-time education for children who cannot attend school is not discretionary. Section 19 of the Education Act 1996 is clear. What these cases also show is that this duty is routinely unmet, often for extended periods — and that the period in which a child has no suitable education, no structure, and no sense of purpose is frequently the period in which risk escalates most sharply.
Child L was academically capable, having achieved six good GCSEs at a specialist school following years of disrupted education. She had no EHCP. A college accepted her, then rescinded her place once they received information about the support she would need. She was left with nothing. An educational psychologist noted she was “feeling stressed, bored and sad.” She was autistic, in care, and known to be acutely vulnerable — she had previously made attempts on her life. The Coroner cited the unexpected withdrawal of her education in the four months leading to her eighteenth birthday, and the resulting lack of purpose, as a direct trigger for her suicidal ideation.
Child O’s family had to take the local authority to tribunal to secure his EHCP and a specialist school place.When the pandemic forced him to shield, there was no replacement support at home, despite his high-risk behaviours being, as the review records, “obvious.” The local authority then removed his EHCP and sought to return him to a mainstream school — a decision overturned in court but which left him out of school for a prolonged period. Despite escalating behaviours and expressed concerns from a wide range of involved professionals, including the police, all requests for additional support were repeatedly declined. He died, aged thirteen.
Child P struggled with the transition from primary to secondary school. Her EHCP had not been completed at the point she entered alternative provision, and staff acknowledged they did not have a full understanding of her needs. Her review records that “no doubt earlier diagnoses would have impacted positively on her care and treatment plan.” When she was discharged from a Tier 4 mental health unit, there was no education provision in place. “[Child P’s] plan was that she would go to college, but the support was not in place.” Her parents had already had to chase to have her EHCP and additional needs formally recognised.
Child Q’s review records that she was “bored” much of the time, had too much time to “think about things,” and that her neurodiversity and mental health needs had required “earlier diagnosis and intervention.” Her father said she had been “let down” by the education system, with significant gaps evident where no educational provision was made for her and no school placement was secured. During the period under review, the safeguarding report records that she did not participate in any meaningful education. Transition planning as she approached eighteen was characterised by drift and delay. Her family believe the impact of this on her mental health was profound.
She died, shortly before her 18th birthday.
Child R’s family fought a lengthy battle with their local authority to secure his EHCP despite an autism diagnosis made when he was six years old. They describe their experience of trying to secure suitable educational support, across a decade, as “Kafkaesque.” During the pandemic, his one-to-one support was reduced to remote contact and he became disillusioned with school. When the family sought specialist CAMHS support for a child with a known autism diagnosis, they were told no such provision existed in their area. A referral to a specialist service was declined because he was not already on the local CAMHS radar. His parents’ statement describes a family “passed from pillar to post desperately looking for help.”
The system reviewing these deaths is not designed to see what happened.
This is perhaps the most consequential finding of all — not what these cases show about what went wrong, but what they reveal about how little of it is formally seen, recorded, or acted upon.
Inquests are designed to establish who the deceased was, and where, when, and how the death occurred. The scope and terms of an inquest are set by the Coroner. As documented by INQUEST (the charity providing expertise on state-related deaths and their investigation in England and Wales), this frequently results in families feeling that many of the underlying and systemic factors contributing to their child’s death are insufficiently examined, if at all.
Inquests are not designed to interrogate compliance with education legislation — particularly where failures are framed as contextual rather than as direct contributors to the immediate circumstances of death.
Family circumstances are almost always examined in detail. Educational history is not.
The consequence is structural and predictable. Published findings and recommendations focus overwhelmingly on failures at the point of acute crisis- most notably within CAMHS, NHS Trusts and hospitals, or immediate high-risk environmental factors such as transport, highways, or access to harmful online content.
These failures are real, often severe, and require urgent attention. But the emphasis on (necessarily) interrogating crisis-stage breakdowns has consistently obscured examination of the prolonged upstream failures that shaped vulnerability over time. Without identifying, investigating, and addressing those systemic factors, critical opportunities for meaningful learning are lost — and the conditions that give rise to crisis are left fundamentally unchanged.
This limitation is further compounded by the absence of consistent identification of neurodivergence or special educational needs within notification and classification processes, meaning that many child deaths involving significant educational vulnerability are not recognisable as such within public records.
As a result, many child deaths are not publicly or consistently identifiable as involving neurodivergent children, SEND support, or statutory EHCP processes. A Prevention of Future Deaths report can only be issued where a Coroner believes a risk of future deaths exists and could be reduced — a judgement necessarily limited by the scope of the inquest itself.
Where educational history is not brought forward, it cannot form the basis of a finding. But the consequence extends beyond individual cases. Where the formal record does not consistently or reliably capture whether a child had recognised special educational needs, whether statutory duties applied to them, or whether those duties were breached, individual cases cannot be identified as instances of a wider pattern.
Failures that are not classified cannot be counted. Failures that cannot be counted cannot be recognised as systemic. And failures that are not recognised as systemic will not be addressed as such — meaning the conditions that gave rise to them remain in place, and the risk to other children remains unaddressed.
The result is that widespread and repeated educational failings are indicated — and in some instances even documented — in factual terms, but remain largely unacknowledged in the public record as matters of statutory non-compliance, despite repeated evidence that families describe these failures as central to the crisis trajectories that followed.
The case of Child M illustrates the consequences of this structural failure with unusual clarity.
The Coroner explicitly noted that local Child Death Review processes had resulted in superficial fact-finding, with no meaningful analysis of the role played by statutory agencies — and went further, stating in a Prevention of Future Deaths report:
“At the prevention of future deaths hearing, I heard evidence concerning the post death reviews conducted into Child M’s death by the [Redacted] Child Death Review Partnership Team and the [Redacted] Safeguarding Children Partnership. The evidence showed that neither process resulted in a sufficient or effective investigation of the death; I consider that the evidence shows that fact finding was superficial, there was no meaningful analysis of the part played by statutory agencies in the causation of his death, and only very limited learning was identified.
Ineffective review by the child death review processes results in the risk of further deaths in similar circumstances and I am concerned that the local and/or national process, guidance and oversight are insufficient to ensure that an effective post death investigation, which should not be dependent on the inquest process, is achieved in all cases.”
Child K’s case further illustrates this invisibility. Her mother’s account, should be read in full:
“When she was going through secondary school, trying to concentrate on anything was a huge difficulty when you’ve got a noisy classroom and she had to tune that noise out. It was a challenge to get any support put in place at first. I was told she needed an official diagnosis first. [Child K] ended up changing secondary schools three times. [she was bullied in all three schools]. They threatened me with court if she wasn’t back in school. So I said to them, we’re going into each school and ending up with the same problems. We need the support in place to help [Child K] that obviously wasn’t put in place. This is when she kind of tipped over the edge, making her go back to [Redacted: School name]. And the school was ringing me up saying I’ve got to come and get her because she couldn’t handle it. So they did make her go but she was so anxious.”
Despite years of deterioration in education which preceded her mental health crisis, the formal Inquest findings and subsequent Prevention of Future Deaths Report are necessarily directed toward what happened in her final days and hours in hospital. There is no evidence in the public record of what, if any, review was undertaken through the Child Death Review or Safeguarding Children Partnership processes to investigate and address the issues experienced by Child K during her education.
Of the 25 cases in this analysis, five children — all with recognised Special Educational Needs — have generated no published safeguarding review, no Prevention of Future Deaths report, and no publicly accessible Inquest findings.
Their deaths do not appear in any published national database. No formal document exists in the public domain that has examined whether the statutory duties owed to them were being met and what changes have been made as a result.
We looked. It appears the system did not.
It is the view of this report that where there is evidence that a statutory duty was engaged — whether or not it was discharged — the death of the child to whom that duty was owed should automatically invoke a statutory investigation into whether that duty was met.
At present, no such mechanism exists.
Across the remaining cases, findings of statutory education failure are present throughout — in what parents describe, in what the case timelines show, in what reviews record as background context. Formal findings of breach of statutory SEND duties are rare. Not because the breaches were absent — indeed this analysis indicates the opposite to be true. These failures are not formally recognised because the review architecture appears not to have been designed to look for them.
Scale of harm beyond formal review.
It is therefore the assessment of this report that the cases analysed represent a small and highly visible subset of a much wider pattern of harm.
They are not the totality of such cases — they represent what is visible in the public record.
At present, it is not possible to state with confidence how many children with special educational needs have died by suicide, nor how many of those deaths were preceded by systemic failure to provide suitable educational support. That question cannot be answered because the necessary data is not consistently collected, categorised, or examined — and because educational history is routinely marginalised within post-death review processes.
This conclusion is reinforced by the primary source testimony database collected by Measure What Matters.
Of the 1,253 testimonies analysed, 204 explicitly reference suicide, suicidal ideation, or repeated suicide attempts. These accounts frequently describe prolonged educational exclusion, unmet SEND, and systemic failure to provide lawful support — leading to educational neglect, social isolation, and escalating mental health crisis. While these testimonies are not statistically representative, they strongly reinforce the conclusion that the scale of risk faced by neurodivergent children through educational failings is substantially greater than that captured by formal post-death review mechanisms.
Within this context, mental health crisis and suicide emerge not as sudden or isolated events, but as the culmination of prolonged vulnerability shaped by systemic educational neglect. And while the circumstances around the death of a child are often complex and multi-faceted, the consistency, severity, and recurrence of the failures in education identified across multiple jurisdictions and multiple years indicate not isolated tragedy, but a national pattern — one operating at a scale that demands urgent, systemic scrutiny.
Put plainly – the same failures recur, across different children, different local authorities, different years. Without consequence, without learning, and without count.
These were not children who fell through the gaps. There were no gaps. There was a legal framework, with clear duties, enforceable rights, and statutory timescales. It was simply not applied. Or tracked. Or scrutinised.
And today, the Government will seek to replace it with something that asks less, requires less, and enforces nothing.
The girl in the opening of this report was thirteen when September came around again.
She was dead by March.
She had an EHCP. Its legally enforceable rights should have protected her…
As of today, those rights look set to be extinguished.
Her name was Eivie.
Measure what Matters.
Measure What Matters would like to express their gratitude to all families who have been involved in sharing testimony to support this project. We believe that the voice of lived experience must inform any meaningful reform.
The families gave their testimony in the hope that it would matter.
We intend to make sure it does.
Detailed case reference mapping will be considered on request. All children have been anonymised in this report. Measure What Matters are committed to handling source material with care, and to protecting the privacy of the children and families whose experiences are represented here.
Measure What Matters. All 1,253 family testimonies are published in full at: Measure what matters. – Empowering Constituents with Clear Insights on Local Government Performance
References.
Primary dataset Measure What Matters, National Database: Measure What Matters — Indexed Testimony on SEND Maladministration, Publication 3, January 2026. 1,253 family testimonies, published in full.
Child safeguarding practice reviews and serious case reviews Local Child Safeguarding Practice Reviews referenced in this piece are available from the National Society for the Prevention of Cruelty to Children (NSPCC) National Database. Full source mapping available on request.
Inquest findings and Prevention of Future Deaths reports Prevention of Future Deaths reports referenced in this piece are available from the Courts and Tribunals Judiciary. Full source mapping available on request.
National data and statutory sources National Child Mortality Database, Learning from Deaths: Children with a Learning Disability and Autistic Children Aged 4–17, Thematic Report, July 2024. Department for Education, SEND and AP statistics, England, annual series. Zero Suicide Alliance, Research and Data Dashboards. Local Government and Social Care Ombudsman, SEND casework data, annual series. ISOS Partnership, Towards an Effective and Financially Sustainable Approach to SEND in England, report commissioned by the Local Government Association and County Councils Network, 2023.
Organisational resources INQUEST, the charity providing expertise on state-related deaths and their investigation in England and Wales.
Suicide prevention guidance Samaritans, Media Guidelines for Reporting Suicide. Available at samaritans.org. Papyrus UK, Guidance for Journalists: Reporting Suicide and Young People. Available at papyrus-uk.org.
Media sources Media reporting and investigative journalism reviewed in the preparation of this report includes coverage from national and regional outlets. Specific articles are available on request.
Please note: The Times national investigation into the deaths of neurodivergent children with SEND, first published 22 February 2026, is referenced directly in the body of this report.
Legal framework referenced Children and Families Act 2014. Education Act 1996, s.19. Equality Act 2010. SEND Code of Practice: 0 to 25 years, Department for Education and Department of Health, 2015 (updated 2020).
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