Girl, 12, died after failings at hospital, inquest jury finds

A 12-year-old girl who took her own life while being detained under the Mental Health Act died following a series of failings by hospital staff, an inquest jury has found.

Mia Lucas was found dead at the Becton Centre at Sheffield Children’s Hospital on 30 January 2024 while suffering from an acute psychotic episode, partly triggered by an underlying brain disorder.

Following a nine-day inquest, jurors found that inadequate testing by staff at Nottingham’s Queen’s Medical Centre (QMC) meant the condition had gone undetected and had “possibly contributed to Mia’s death”.

Speaking after the hearing Mia’s mother Chloe Hayes said she would “never forgive” those responsible for the “failure to provide appropriate care to her in her time of need.”

The inquest heard how Mia, from Arnold in Nottinghamshire, began to behave strangely over Christmas 2023 – hallucinating and hearing voices telling her to harm herself and her family – and was taken to QMC on New Year’s Eve.

Whilst there she was found to be experiencing an “acute psychotic episode” and was sectioned under the Mental Health Act.

The jury of five women and four men heard that blood tests and an MRI scan were carried out but came back negative and doctors ruled out a physical cause of Mia’s psychosis.

However, a lumbar puncture, which may have revealed she was suffering from the rare disorder autoimmune encephalitis which would have caused the acute psychosis, was not carried out.

The jury said this meant “potential indicators… were missed”.

Dr Manjeet Shehmar, Medical Director at Nottingham University Hospitals NHS Trust, said: “I would like to offer my heartfelt condolences to Mia’s family for the loss of their daughter.

“We accept the coroner’s outcome in court today and apologise to Mia’s family for not identifying autoimmune encephalitis while she was in our care.

“While this is an incredibly rare condition and initial tests were negative, we recognise that further testing may have had an impact on her future, for which we are truly sorry.”

Mia was transferred on 9 January to the Becton Centre, one of the only mental health units in the country suitable for children aged 13 and under.

However, the jury found the information passed between QMC and the Becton Centre “provided an inappropriate level of assurance that organic causes had been ruled out”.

While there Mia tried to harm herself four times, including on the morning of her death – an incident which failed to be logged in the shift handover notes – and was described as being “changeable and distressed”.

But on the night of Mia’s death Ms Hayes said she was told she was “settled”.

However, she received a phone call just after midnight to tell her Mia had self-harmed again and it was found that she did not have a pulse.

The jury said while at the unit “insufficiently robust communication and management of risk had led to a failure to respond adequately to Mia’s risk of self harm”.

Ms Hayes said: “It has been devastating to listen to how, when she needed specialist healthcare, for the first time in her life, she was so badly let down.

“She was let down at the Queen’s Medical Centre in Nottingham, who wrongly decided there was no underlying physical cause of her psychosis, and failed to carry out appropriate testing.

“I believe they simply dismissed her and looked to pass her onto mental health services as quickly as possible, which led to her transfer to the Becton Centre.

“Her mental health spiralled deeper out of control there, as she was not being treated for her condition, and the many failings and lack of care meant sadly she wasn’t properly protected from harming herself.

“My beautiful little girl has lost her life and I will never forgive the Queen’s Medical Centre or the Becton Centre for failing her.”

She added: “I have never believed for a moment that Mia ever wanted to take her own life.

“She was always a happy, healthy child and had so much to live for.”

A spokesperson for Sheffield Children’s NHS Foundation Trust said: “The inquest has been important to understand fully the circumstances surrounding Mia’s death.

“We will now carefully reflect on the evidence heard and the coroner’s conclusions to ensure we continue to provide safe and compassionate care.”

The inquest heard how since Mia’s death the Becton Centre has made a number of changes to the facility.

Due to these “substantial and robust” changes, senior coroner Tanyka Rawden did not issue a Prevention of Future Deaths report.

She said she would also not be issuing one for the Queen’s Medical Centre either, giving it six months to implement its changes.

However Mrs Rawden said she would be writing to Health Secretary Wes Streeting to raise her “concerns” regarding national guidelines into autoimmune encephalitis.