A 15-year-old boy described as 'loving' and 'quirky' was tragically found dead at his home in Oldham after his mother had been out for just an hour, a coroner's court has heard.
Systemic Failures in Care and Support
Zack Ellis, who had been assigned female at birth but identified as male from a young age, had been receiving support from multiple agencies for his mental health. This included the Child and Adolescent Mental Health Services (CAMHS) under the NHS Pennine Care Trust and social services at Oldham Council.
His mother, Kathleen, discovered his body in his bedroom on 23 July 2024 upon returning from giving a friend a lift. Greater Manchester Police Detective Chief Inspector Hunter told Rochdale Coroner's Court that while no suicide note was found, Zack's phone search history revealed he had looked up 'how to kill myself' online just two hours before he was discovered.
The hearing, which took place on 15 January 2026, was told Zack's mental health had begun to deteriorate in mid-2022, leading to self-harm. He had told mental health practitioners he was suicidal most days and had been self-harming since the age of 11. He also experienced trouble sleeping and auditory and visual hallucinations.
Missed Opportunities and Communication Breakdowns
Despite being under a child protection plan following a domestic violence incident within the family, critical gaps in his care emerged. The family had requested an assessment for ADHD and autism, which appears to have never been actioned.
Alarmingly, CAMHS staff were not included in his multi-agency care meetings, nor were statements requested from his GP, despite supposed 'open communication'. Social worker Francesca Horsefield later acknowledged to the coroner that CAMHS should have been invited.
Several escalating incidents were highlighted during the inquest:
- On 20 March, Zack posted suicidal ideation on social media, but a social worker decided the 'threshold of escalating risk was not met'.
- On 11 June, he brought a blade to college and had what appeared to be a knife mark on his neck.
- On 18 June, he arrived at college 'very distressed' after a private video was shared on social media.
Despite these clear warning signs, Zack was discharged from the Tameside CAMHS service in June 2024 after missing three appointments and was placed on the waiting list for Oldham services.
A Family's Love and a System's Shortfall
Zack was remembered by his mother as an 'awesome' lad and 'the best big brother' to his siblings. He had a passion for art and photography and was said to 'love' his college, Salford City University Technical College, which he joined at 14.
His mother Kathleen acknowledged 'things were challenging at home' but emphasised their close bond. She stated, "I would help him clean his wounds and be a shoulder for him to cry on." A safety plan had been implemented, including hiding sharp objects in the home.
Senior Coroner for Manchester North, Joanne Kearsley, recorded that the medical cause of death was hanging. The inquest continues to examine the full circumstances surrounding the tragic loss of the teenager, who was just 40 minutes away from his mental health service but often enjoyed the long walk to 'clear his head'.
