6mBy Jamie Roberton
A 12-year-old woman was affected by an undiagnosed uncommon mind situation when she was in a position to fatally hurt herself inside an NHS kids’s psychiatric unit, a jury has discovered.
Mia Lucas, described as “full of sunshine and pleasure”, died after being discovered unresponsive in her room on the Becton Centre in Sheffield on 29 January 2024.
She had been sectioned after experiencing a severity of psychosis described as “extraordinary” in her age group.
Medical exams following Mia’s loss of life revealed that the schoolgirl had autoimmune encephalitis, a bodily dysfunction leading to mind irritation that may trigger excessive psychiatric signs.
The jury broke down in tears at among the proof heard in the course of the 10-day inquest, discovering unanimously that Mia had been let down by the NHS on a number of ranges.
The failure to conduct a selected lumbar puncture take a look at at Queen’s Medical Centre in Nottingham – the hospital the place Mia was initially taken – to diagnose the situation was discovered to have probably contributed to Mia’s loss of life.
Care on the Becton Centre was additionally discovered to be inadequate, with an absence of strong communication and administration of threat.
Chloe Hayes, Mia’s mom, informed Channel 4 News: “Mia has misplaced her life due to the poor care and observe of those locations.”
Sudden decline
Mia, who aspired to turn into a vet or open her personal magnificence salon, had skilled bullying when she began secondary college however was beforehand in good well being.
The 12-year-old had suffered a viral an infection earlier than her well being quickly deteriorated in the direction of the top of 2023, together with her household witnessing “unusual behaviour” that was out of character.
This included an incident on a motorway by which she attacked her mom and tried to seize the steering wheel of the automobile.
Mia described listening to voices that had been turning into “nastier over time”, with the 12-year previous claiming she believed she would “need to do issues or one thing unhealthy would occur to her household”.
Mia described listening to voices that had been turning into “nastier over time”
She was rushed to Queen’s Medical Centre on New Year’s Eve in 2023 after taking out a knife on the household house and saying “she wanted to go to heaven”.
Ms Hayes mentioned her daughter seemed “genuinely terrified” by what was occurring to her, earlier than she was sectioned below the Mental Health Act and later transferred to the Becton Centre, a specialist kids’s psychological well being facility for under-13s.
Admission to hospital
Chloe Hayes informed the court docket that she would cellphone the unit at 8am every day to examine in on Mia, earlier than visiting each evening of the week.
Ms Hayes mentioned she quickly grew to become more and more involved about her daughter’s security inside, alleging that she acquired contradictory info from nursing employees and was not assured that common commentary checks had been happening.
“Mia had massive desires for her future and an enormous coronary heart to match.”
Mia tried to hurt herself on a minimum of 4 events, the inquest was informed, incidents that weren’t recorded totally in her medical notes.
”When I went to see Mia, it was a large shock,” Ms Hayes mentioned. “Her brow was utterly swollen, she had two huge black eyes, the highest of her head was utterly bald and she or he had completed that together with her arms. Mia had no recollection of it.”
She added: “That’s after I first mentioned to employees, this isn’t ok. It wasn’t proper that there had been so many incidents in such a small time – they didn’t appear to take it severely”.
Mia was discovered fatally injured in her room after 11pm on 29 January 2024, lower than a month after she was sectioned.
The jury and members of the general public gallery cried as Ms Hayes recalled how she visited Mia at a mortuary each day till her funeral.
“Mia had massive desires for her future and an enormous coronary heart to match,” Ms Hayes informed jurors. “Her coronary heart was big and there was room in it for everybody.”
New medical info
At the beginning of the second week of inquest proceedings, jurors had been informed of recent info from autopsy blood exams which confirmed that Mia was affected by autoimmune encephalitis.
Professor Marta Cohen, a pathologist, mentioned Mia’s medical explanation for loss of life remained “compression of the neck” however that this was now attributable to “acute psychosis”, triggered by “autoimmune encephalitis”.
“There’s in all probability extra kids like Mia who’ve been despatched to a psychiatric unit with a bodily medical downside.”
Asked how she felt upon studying of the prognosis almost two years on from her daughter’s loss of life, Ms Hayes mentioned: “I really feel much more devastated. Mia may have had remedy and would nonetheless be right here at the moment – she ought to by no means have gone to the Becton Centre.”
She added: “There’s in all probability extra kids like Mia who’ve been despatched to a psychiatric unit with a bodily medical downside.”
Calls for nationwide steering
After deliberating for simply over a day, the jury discovered that info on Mia’s case handed from Queen’s Medical Centre to the Becton Centre “lacked enough element” and featured “inappropriate stage of assurance that bodily exams had been completed”.
Failings recognized on the Becton Centre included “insufficiently strong communication and administration of threat”.
Nottinghamshire University Hospital accepted {that a} lumbar puncture ought to have been performed on Mia and that the take a look at was now carried out extra usually when autoimmune encephalitis is suspected.
Sheffield Children’s NHS Trust mentioned it had improved security on the Becton Centre following Mia’s loss of life, which included altering all doorways on the unit, strengthening employees handovers and never accepting any baby into its care till seeing proof of full bodily examinations.
Senior Coroner Tanyka Rawden mentioned she would write to the Health Secretary Wes Streeting to name for nationwide steering on testing for autoimmune encephalitis, warning there remained a threat that future deaths would happen.
Ending the proceedings, the senior coroner paid tribute to Mia, saying: “She was clearly somewhat woman with an enormous coronary heart and an enormous character. I can’t think about what you as a household have been by means of – I hope that the inquest has answered a few of your questions.”
In a press release, Nottingham University Hospitals mentioned: “We settle for the coroner’s consequence in court docket at the moment and apologise to Mia’s household for not figuring out autoimmune encephalitis whereas she was in our care. While that is an extremely uncommon situation and preliminary exams had been destructive, we recognise that additional testing might have had an affect on her future, for which we’re really sorry.”
A spokesperson for Sheffield Children’s NHS Trust mentioned: “We are deeply sorry for Mia’s loss of life and recognise the profound affect this has had on those that cherished her. Following Mia’s loss of life in January 2024, we carried out an intensive assessment of her care and have made vital adjustments on the Becton Centre”.
