A coroner's court has heard the tragic details surrounding the death of a 15-year-old boy who was found at his home after his mother had been out for just one hour.
A 'Loving' Boy Struggling with Mental Health
Zack Ellis, described by his mother Kathleen as an "awesome", "loving" and "quirky" lad, was discovered in his bedroom on 23 July 2024. His mother found him upon returning to their Oldham home after giving a friend a lift. The inquest at Rochdale Coroner's Court heard that Zack had been grappling with his mental health for some time.
DCI Hunter of Greater Manchester Police told the hearing that while no note was found, Zack's phone search history showed he had looked up 'how to kill myself' online just two hours before he was found. Zack, who was passionate about art and photography, had moved to Salford City University Technical College when he was 14.
History of Support and Missed Interventions
The court was told Zack had been receiving assistance from multiple agencies, including the Child and Adolescent Mental Health Services (CAMHS) at NHS Pennine Care Trust and Oldham Council's social services. He had been assigned female at birth but began identifying as male from a young age, adopting the name Zack at around 12 years old.
Following a domestic violence incident, Zack and his siblings were placed under a child protection plan. Family social worker Francesca Horsefield said Zack had disclosed a sexual assault in November 2023 but chose not to involve police. A safety plan was created, which included removing sharp objects from the home.
Zack was referred to CAMHS in 2023 and received a second referral in January 2024 after two overdose incidents the previous December. Mental health practitioner Phillip Bates said in a statement that Zack told him he was "suicidal most days" and had been self-harming since age 11.
System Failures and Discharge from Care
Despite these known risks, the inquest heard of several potential failings. Student social worker Charlotte Fisher, Zack's CAMHS worker between April and June 2024, said they had a "good relationship". However, Zack was discharged from the Tameside CAMHS service in June 2024 after three missed appointments, as it was felt he didn't always benefit from talking therapy.
He was then placed on the Oldham waiting list. Senior Coroner Joanne Kearsley questioned why a troubling social media post from Zack on 20 March, which expressed suicidal ideation, did not trigger an escalated response. Tracey Lockie of Oldham Council acknowledged that "in hindsight a strategy meeting should have been held".
Further alarming incidents occurred. On 11 June, Lee Berry, vice principal at Zack's college, reported that Zack had brought a blade into college and had a mark on his neck. A week later, on 18 June, Zack arrived at college "very distressed" because a private video he had sent was being shared on social media.
By 25 June, he had been discharged from CAMHS. At a final child protection meeting on 11 July, just days before his death, Ms Horsefield noted Zack seemed "really upbeat". When asked what she would do differently, she responded: "Invite CAMHS into our meetings."
Coroner's Findings and Family's Loss
Senior Coroner for Manchester North, Joanne Kearsley, stated the pathologist gave the medical cause of death as hanging. The inquest continues to examine the full circumstances.
Zack's mother Kathleen told the court she was unaware of his self-harming at first, but later would "help him clean his wounds and be a shoulder for him to cry on". She acknowledged "things were challenging at home" but emphasised their close bond. The family had also requested an ADHD and autism assessment for Zack, which appears not to have been pursued.
Zack, who spent his childhood in Stalybridge before moving to Oldham in 2023, was remembered as "the best big brother to his siblings". For emotional support, you can call the Samaritans 24-hour helpline on 116 123, email jo@samaritans.org, visit a branch in person or go to the Samaritans website.
