'Inadequate' planning a factor in teenager's death

Inadequate aftercare support contributed to an "extremely vulnerable" 15-year-old girl taking her own life six weeks after being discharged from hospital, a coroner has ruled.

Evelyn Gibson, from Grantham, who had a history of complex mental health issues, was admitted to the Beacon Unit, a general adolescent inpatient unit at Glenfield Hospital, Leicester, in July 2021.

She was discharged for a second time on 1 March 2022 and killed herself on 15 April.

Area coroner Jayne Wilkes told an inquest in Lincoln that the "inadequacy" of discharge planning at the Beacon Unit and "incomplete" aftercare plans "did make a contribution to her death".

Ms Wilkes also found there was a "lack of consideration for significant concerns raised by Evelyn's family" throughout the discharge process.

The funding for required aftercare support for Evelyn had been identified and agreed but was never put in place, the court heard.

This included a gap in support between the hours of 19:00 and 21:00, which was a time of the day Evelyn had told medical professionals she "struggled to handle her thoughts".

Ms Wilkes said: "I am satisfied... that the inadequacy of her discharge planning throughout her time at the Beacon Unit, which meant that, at the time of Evelyn’s discharge and even up to her death, the arrangements for her aftercare remained incomplete, did make a contribution to her death."

Evelyn was first discharged from the Beacon Unit in late December 2021 but placed back on the ward a few days later after several self-harm attempts.

Dr Abhay Rathore, a consultant psychiatrist at the Beacon Unit before Evelyn was first discharged, initially submitted a referral to the Paediatric Intensive Care Unit for Evelyn.

In early November he said he noticed an "improvement in Evelyn’s mood and decrease in high risk behaviours".

He introduced 2:1 staffing support for Evelyn in the evenings as he saw a pattern of "reasonably OK-ish daytime, but the evening was hard for her".

The court heard that Evelyn’s mother, Jennifer Swift, had been made aware on 23 November of the 21 December discharge date, and had expressed concerns.

Dr Rathore told the court that his belief was if they could get Evelyn’s mental health to "a safe place then remaining help can be in the community".

Alex Longmore, clinical lead at Lincolnshire CAMHS (Children And Mental Health Services), attended a meeting on 7 December with Evelyn’s parents to propose the discharge later in the month.

"I felt that we had a relatively good understanding of what needs were required and felt comfortable enough from a CCETTS (CAHMS Crisis and Enhanced Treatment Team) perspective of what we were able to offer," he told the court.

Referring to the second discharge, Mr Longmore said he did not see the gap in evening support as a "barrier to prevent discharge" and that "everyone appeared to agree that things felt more positive this time".

However, Ms Wilkes said: "The professionals dealing with Evelyn also knew the huge pressure and responsibility they had placed on Evelyn’s family, care which... could not be replicated at home.

"I am satisfied that the State was responsible in part for this danger, and I am satisfied Evelyn was, from her behaviours, at real and significant... risk to life."

Eve Baird, chief operating officer at Lincolnshire Partnership NHS Foundation Trust said: "We were saddened that the coroner concluded that elements of Evelyn’s care fell below the standards we would hope for our families.

"We remain committed to delivering the very best care to children, young people and their families when they struggle with their mental health and wellbeing.

"We have worked very closely with Evelyn’s family to understand their experiences, completed a thorough review and made changes in response to learning we have taken from Evelyn’s tragic death."

A spokesperson from Leicestershire Partnership NHS Trust (LPT) said: "We offer our sincerest condolences to Evelyn’s family and friends for their loss.

"We are committed to providing the best quality care for our patients and to being a continuously learning and improving organisation.

"We undertook an internal investigation to highlight any learning from this tragic event and to ensure that our services meet the highest standards of care that our young people deserve."

Evelyn’s mother and stepfather, Jenni and Jack Swift, said: "As anyone can imagine, reliving our daughter’s death, and the traumatic years leading to her death, has been very difficult, and we have been grateful for the sensitivity and dignity we have been treated with.

"While we have been taken back to some devastating events, we have also been reminded of the input of some remarkable and dedicated professionals involved in Evelyn’s care.

"Evelyn was incredibly loved and is profoundly missed by so many people. She made us proud every single day and continues to do so."

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