Coroner warns new health secretary over lack of paediatric mental health beds

A coroner has written to the new health secretary after an inquest concluded that a lack of paediatric mental health beds contributed to the suicide of a teenager.

The inquest into the death last year of 15-year-old Madeleine Savory, who identified as non-binary, found that the lack of a Tier 4 bed in a paediatric mental health facility ‘possibly more than minimally contributed to Madeleine’s death’. 

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Following the conclusion of the inquest, Darren Stewart, the area coroner for Suffolk, wrote a prevention of future deaths report (PFD) to health secretary Victoria Atkins and NHS England warning that the national shortage of Tier 4 beds could lead to more deaths in future.

The PFD report listed as a matter of concern ‘the availability, nationally, of Tier 4 beds in paediatric mental health facilities to allow for the timely allocation to children in need of care in such facilities such as Madeleine Savory’.

Savory took their own life in February 2022 while suffering from the effects of a mental health illness. They had not been formally diagnosed, but at the time of their death clinicians were working considering a working diagnosis of mood disorder depression of a severe nature.

After absconding from their school, Madeleine self-harmed resulting in hospitalisation. ‘They were subsequently identified as needing a Tier 4 Bed admission on a paediatric mental health ward,” the PFD report said. “Measures were put in place for such a bed to be sourced. At the time of Madeleine’s death a bed was neither identified nor allocated to Madeleine.’

Madeleine instead stayed on Bergholt Ward at Ipswich Hospital. The inquest identified a number of failings at Ipswich Hospital, including the ceasing of mental health observations for unclear reasons.

Five days after these measures were ceased, Madeleine went to the bathroom unobserved and secured the door, with their whereabouts unknown to staff for around ten minutes. When staff subsequently gained entry to the bathroom, they found that Madeleine had attempted suicide, and Madeleine died from hypoxic brain injury a week later.

The PFD report said that East Suffolk and North Essex NHS Foundation Trust – which runs Ipswich Hospital – and Madeleine’s school had put in satisfactory measures to address the failings that had arisen at the inquest. East of England NHS providers also said they had undertaken measures to address the regional lack of Tier 4 paediatric mental health beds.

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More on this topic:

Poverty intensifies mental health problems for parents and children

A third of children in care face school exclusion, new research shows


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