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Coroner finds clear failings at A&E which failed to support suicidal teenager Lee Ridgway

28 June 2017

Before HM Assistant Coroner Alison Mutch OBE
Manchester South Coroner’s Court
19 June 2017 – 28 June 2017

Today the inquest concerning the death of 16 year old Lee Ridgway closed, with the coroner concluding the death was suicide with a critical narrative. On 27 August 2016, Lee made an attempt to take his own life and was taken to Stepping Hill Hospital by paramedics along with his parents. After leaving the hospital in the morning of the 28 August, Lee took his own life at Bramhall train station later that day.

The Coroner identified in her summing up that there were clear failings on the part of Stepping Hill Hospital that probably contributed to Lee's death. Lee was triaged as a 'yellow' priority and should have been seen by a clinician within one hour from the point of being booked in. It was identified that staff incorrectly thought a yellow priority ought to be seen within two hours. This wasn't achieved, and neither the reasons for delay nor the likely timescales were communicated to the family. In fact the family waited for four hours before they were told there would be a further four hour wait until a clinician was available to see Lee.

Evidence was heard that communication regarding the level of risk Lee posed to himself and delays in treatment between the staff and Mr and Mrs Ridgway was very poor. Mr and Mrs Ridgway were left to manage their vulnerable son alone, struggling to keep him in the department. They were not given assistance by staff and eventually made the difficult decision to leave as they could not keep Lee safely in the department any longer.

The inquest established that no mental health worker was contacted throughout the family’s communication with the hospital. The inquest also heard that in the months leading up to his death, Lee had made positive progress and appeared more settled and happier. However it became apparent that as soon as this improvement was noted, certain services who had been supporting Lee were stepped down.

No prevention of future death report was issued as the Coroner noted significant changes had been made within Stepping Hill and Stockport children's services following Lee’s death.

Lee Ridgway’s family issued the following statement [extract]:
“The death of our son Lee in August 2016 has completely devastated our family. Lee was a kind, funny and intelligent boy who lived life to the full…. We have been alarmed at the catalogue of failings, discrepancies and incompetence of agencies within Stockport Children’s Services during the time that we requested support from them. We have received a number of verbal apologies from them in the courtroom. We do however acknowledge that particular individuals gained Lee’s trust, namely pastoral teachers and MOSAIC workers.  Their help and positive engagement was so beneficial.

In addition we wish to express our anger and disgust at the complete lack of care provided to Lee by Stepping Hill Hospital when he was at his most vulnerable. Paramedics took Lee to Stepping Hill in a manic and suicidal state fully knowing he was intoxicated and in crisis. We were left by ourselves to look after him on a chaotic corridor as he continually tried to escape and we struggled to safeguard him.”

The full family statement is available here. The family will be giving no further comment.

Nicole Bridgman of Southerns Solicitors who represented the family said: 
“Lee’s tragic death highlights the importance of appropriately treating and potentially assessing mental health issues in a timely manner. The A&E staff didn't contact anyone from the mental health team at any point when Lee was in their care. Nor did they contact mental health staff the following day despite stating that whey would.

Lee’s parents were left in a truly unimaginable situation by Stepping Hill staff, as they tried to cope with Lee at his most desperate point. It could and should have been avoided. This is another situation whereby the treatment and support offered to assist someone in a crisis fell far short of what was required. The evidence heard during the inquest identified failings by staff at Stepping Hill hospital and amplifies the ongoing need for improvements and changes that need to be made to our existing systems and the current attitude towards those in crisis. We welcome the comments made by the Coroner in her summing up and conclusions.”

Deborah Coles, Director of INQUEST said:
“The lack of support given to Lee’s parents in their attempt to access emergency mental healthcare is shameful. This case reinforces widespread concerns on support for those in mental health crisis. We are particularly concerned about a lack of adequate mental health provision for children. Until there is urgent investment in specialist services across the country these tragic deaths will continue.”

INQUEST has been working with the family of Lee Ridgway since his death. The family is represented by INQUEST Lawyers Group members Nicole Bridgman of Southerns Solicitors, and Simon Murray of St Johns Buildings Chambers.

ENDS

NOTES TO EDITOR
For further information, please contact: Lucy McKay on 020 7263 1111 or lucymckay@inquest.org.uk

• The family statement is available here. The family will not be giving interviews or further statements at this time.
• Further details issued at the opening of the inquest can be found here.

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