Coroner identifies missed opportunity in schoolgirl’s care at hospital

A coroner has expressed apprehension that a hospital’s emergency department failed to implement guidelines which might have contributed to preventing a girl’s fatality. Erin Tillsley, a 14-year-old from Great Cornard, Suffolk, died by suicide in July of the previous year, following difficulties with her school attendance. Subsequent to an inquest, Darren Stewart OBE, the area coroner for Suffolk, stated that a “missed opportunity” occurred to intervene promptly with the teenager during her visit to West Suffolk Hospital’s emergency department several months before her passing. The West Suffolk Hospital NHS Foundation Trust indicated that it has since made certain that all personnel are cognizant of the procedures within the children’s referral pathway. An inquiry into Miss Tillsley’s death concluded on 31 May of the current year. Mr Stewart issued a Prevention of Future Deaths Report in the current month. His report elaborated that Miss Tillsley experienced challenges with her school attendance after the lifting of Covid-19 pandemic restrictions in 2022. Towards the close of that year, she endured a challenging time with a friend, and following an incident of self-harm, she was transported to West Suffolk Hospital in Bury St Edmunds on 31 December. Her physical symptoms underwent assessment but were “not considered serious,” leading to her discharge the subsequent day. In his report, Mr Stewart stated: “Emergency department staff at the West Suffolk Hospital did not consider a referral to psychiatric liaison services to be appropriate during the admission; however advice was given for a referral by Erin’s GP to mental health services.” Mr Stewart noted that testimony presented during Miss Tillsley’s inquest suggested that established guidance was not followed in the teenager’s care and treatment during her hospital stay. This encompassed National Institute for Health and Care Excellence (NICE) recommendations concerning self-harm, alongside directives from Suffolk and North East Essex and Suffolk County Council’s collaborative policy on assisting children and young people experiencing crises. Mr Stewart remarked: “The failure to apply this guidance/policy meant that there was a missed opportunity for mental health services to engage early with a vulnerable child who had presented to the emergency department having [self-harmed].” On the day of her death, Miss Tillsley was scheduled to commence at a new school but informed her father of her intention not to attend. Her father subsequently discovered her unresponsive, and paramedics declared her deceased at the location. Dr. Ewen Cameron, chief executive of the West Suffolk NHS Foundation Trust, conveyed that the trust was “deeply saddened” by Miss Tillsley’s death. He further stated: “Every patient deserves the highest quality and safest care and we have rightly carried out a patient safety review regarding Erin’s care with us.” He mentioned that the trust had received Mr Stewart’s report and planned to conduct additional reviews of its procedures. The trust reported that since Miss Tillsley’s inquest, it has delivered continuous training and education on involving services from colleagues within its mental health liaison team. It also stated that it had collaborated with other entities in Suffolk and north east Essex to examine the protocols pertaining to children and young people in crisis. Individuals impacted by any of the subjects discussed in this article may access the BBC Action Line. For updates on Suffolk news, follow BBC Sounds, Facebook, Instagram, and X. Copyright 2024 BBC. All rights reserved. The BBC bears no responsibility for the content of external websites. Information regarding our approach to external linking is available.