Shay Middleton-Pierce, aged 15, took his own life on railway tracks near Redhill on 29th March 2025 after he had been reported missing to Surrey Police the previous day when a friend raised concerns for his wellbeing. Following a nine-day inquest, the jury found that there were several failures by Surrey Police and British Transport Police in their response to Shay which possibly contributed to his death.

On 27th March 2025, Shay's school contacted the police after Shay had not shown up in school and a friend had raised concerns about his wellbeing, following receipt of a message from Shay expressing thoughts of suicide. During the initial 999 call, the message sent by Shay was incorrectly recorded on the police accident log (CAD), with the wording entered being less indicative of an immediate risk to his life than the words actually used by Shay. The evidence heard at the inquest was that this error affected the risk assessments and decision-making of the inspectors in charge of the investigation, who did not initially record Shay as a missing person but rather a concern for safety.

Shay's friend was able to identify his location through social media location tracking, which indicated that he was on a train. The British Transport Police were informed and assessed the report as requiring immediate action. However, the log was then removed from their dispatch queue, meaning the British Transport Police officers were not dispatched and Surrey Police were not informed that British Transport Police would not be attending.

Surrey Police also failed to deploy officers to find Shay after he had disembarked from the train, despite having information as to his approximate location. He was only recorded as a medium-risk missing person later that night. Officers who were then tasked with searching for Shay in the early hours of the morning were diverted to another incident, and no further officers were deployed to search for him.

After hearing evidence from a number of witnesses and experts over the course of six days, the jury concluded that seven failures by the police forces may have been contributed to Shay's death:

1. There was a mis-recording of Shay's snapchat message to his friend on the CAD during the 999 call and an omission to record contact details of the teacher, friend or school which had repercussions for the investigation in respect of Shay's risk assessment and the onward actions and timescales associated with that.

2. There was a failure to record the phone details for Shay's two friends who were in contact with him during 28th March 2025 and at times aware of his location to enable further enquiries to be made.

3. There was a failure by BTP to update Surrey Police that they were not attending Redhill station when the log was moved from the dispatch queue to sub queue at 14:13

4. There was a failure by Surrey Police to deploy to Redhill station or Fairfax Park upon review of log entry at 14:51

5. There was a failure by Surrey Police to deploy a unit to Shay's friends address to speak to his two friends prior to the attendance of a PC on the evening of 28th March 2025.

6. Surrey Police failing to record Shay as a missing person prior to 22:54.

7. There was a failure by Surrey Police to search the Nutfield area once this became clear that this was Shay's last known location as indicated on Snapchat.

Following the receipt of further evidence in relation to the Prevention of Future Deaths process, the Coroner issued a Prevention of Future Deaths report concerning the removal of the British Transport Police log from the active dispatch queue, which prevented them from responding to the incident.

The Coroner noted that the dispatcher was unable to explain during the inquest why the log had been removed from the dispatch queue, other than to describe it as human error, and expressed concern that there were insufficient safeguards and oversight in place to prevent such an error from occurring.

British Transport Police has since responded to the Prevention of Future Deaths report, acknowledging that safeguards intended to prevent such an error were "insufficiently robust in practice" and confirming that these safeguards have now been reviewed.

Jack Middleton, Shay's father said:

During the inquest, we heard evidence about the different ways in which Shay was failed by the authorities in the lead-up to his death. It was deeply disappointing that no apology was offered by the police forces involved. I found the attitude of some of the witnesses to be lacking in empathy, and at times it felt as though their focus was on protecting themselves rather than acknowledging the impact of what had happened. This only added salt to the wounds of losing my son.

While I am very grateful to the Coroner and her staff for their commitment and dedication in helping to uncover what happened, i found the inquest process to feel rushed at times. In particular key evidence such as the IOPC investigation report was disclosed only days before the final inquest began. I was disappointed that the IOPC investigation did not consider the conduct of all key members of police staff involved in Shay's missing person investigation, whose conduct in my opinion warranted further scrutiny.

It was concerning to hear during the Prevention of Future Deaths evidence that similar concerns relating to BTP had arisen following an earlier incident in 2023, and that by the time of Shay's death, further action was still required to ensure that the lessons identified had been properly implemented. It was also upsetting that at the time of Prevention of Future Deaths evidence, it emerged that a correct version of a policy document in force at the of Shay's death had not been disclosed earlier.

Losing Shay has deeply impacted me. He was my world and i am lost without him. Our little family has a hole where Shay used to be. Although his life was short, he managed to have an impact on so many people. I loved my son and his loss is not just a loss to me but a loss to this world that someone so kind, caring and gentle is no longer here.

Shay's father is represented by Keiu Kikas, Felix Parsons and Qaizaar Bharmal of GT Stewart Solicitors instructing John Hobson of Doughty Street Chambers.

Other Interested Persons represented included Surrey Police, British Transport Police and Independent Office for Police Conduct.