Coroner Rules Insufficient Aftercare Contributed to Teenager’s Death

A coroner has determined that insufficient aftercare support played a role in the death by suicide of an “extremely vulnerable” 15-year-old girl, which occurred six weeks following her release from hospital. Evelyn Gibson, a resident of Grantham with a history of intricate mental health challenges, was admitted to the Beacon Unit, which is a general adolescent inpatient facility located at Glenfield Hospital in Leicester, during July 2021. Her second discharge took place on 1 March 2022, and she died by suicide on 15 April. Area coroner Jayne Wilkes stated during an inquest held in Lincoln that both the “inadequacy” of the discharge planning at the Beacon Unit and “incomplete” aftercare plans “did make a contribution to her death”. Furthermore, Ms Wilkes identified a “lack of consideration for significant concerns raised by Evelyn’s family” at various stages of the discharge process. The court was informed that while the necessary funding for Evelyn’s aftercare support had been identified and approved, it was never implemented. This specifically involved a period without support from 19:00 and 21:00, a timeframe during which Evelyn had previously informed medical professionals that she “struggled to handle her thoughts”. Ms Wilkes declared: “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’s initial discharge from the Beacon Unit occurred in late December 2021; however, she was readmitted to the ward within a few days following multiple self-harm attempts. Dr Abhay Rathore, who served as a consultant psychiatrist at the Beacon Unit prior to Evelyn’s first discharge, initially referred Evelyn to the Paediatric Intensive Care Unit. He stated that in early November, he observed an “improvement in Evelyn’s mood and decrease in high risk behaviours”. He implemented 2:1 staffing support for Evelyn during the evenings, having identified a pattern of “reasonably OK-ish daytime, but the evening was hard for her”. It was revealed in court that Evelyn’s mother, Jennifer Swift, was informed on 23 November about the 21 December discharge date and subsequently voiced her concerns. Dr Rathore informed the court of his conviction that if Evelyn’s mental health could reach “a safe place then remaining help can be in the community”. Alex Longmore, who serves as the clinical lead at Lincolnshire CAMHS (Children And Mental Health Services), was present at a meeting on 7 December with Evelyn’s parents to suggest her discharge later that month. He testified in court: “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.” Regarding the second discharge, Mr Longmore stated that he did not perceive the absence of evening support as a “barrier to prevent discharge” and that “everyone appeared to agree that things felt more positive this time”. Nevertheless, Ms Wilkes commented: “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.” She further stated: “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, the chief operating officer at Lincolnshire Partnership NHS Foundation Trust, remarked: “We were saddened that the coroner concluded that elements of Evelyn’s care fell below the standards we would hope for our families.” She added: “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.” Baird continued: “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 for Leicestershire Partnership NHS Trust (LPT) conveyed: “We offer our sincerest condolences to Evelyn’s family and friends for their loss.” The spokesperson further stated: “We are committed to providing the best quality care for our patients and to being a continuously learning and improving organisation.” They also mentioned: “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.” Jenni and Jack Swift, Evelyn’s mother and stepfather, commented: “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.” They added: “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.” Their statement concluded: “Evelyn was incredibly loved and is profoundly missed by so many people. She made us proud every single day and continues to do so.” For individuals impacted by this account, the BBC Action Line web page offers a compilation of organizations prepared to provide assistance and guidance. Further content from Lincolnshire is available on BBC Sounds, the most recent episode of Look North can be viewed, or story suggestions can be submitted via the provided link. Copyright 2024 BBC. All rights reserved. The BBC bears no responsibility for the content found on external websites. Information regarding our policy on external linking is available.