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Coroner’s report on death of 14-year-old girl raises serious concerns over Priory-run mental health unit
A coroner has alerted the Secretary of State for Health Jeremy Hunt of serious concerns over the care and treatment of a 14-year-old girl who died at a high dependency mental health unit run by the Priory Group.
Amy El-Keria was found collapsed in her room with a ligature around her neck at Ticehurst House in Sussex on 12 November 2012. She was taken to hospital but never regained consciousness. A jury at the inquest into her death earlier this year concluded that gross failings in the Priory’s care contributed to Amy’s death.
In the same week that a report by the Care Quality Commission acknowledged systemic failures by the NHS to investigate deaths in its care, Her Majesty’s Coroner Penelope Schofield issued a ‘prevention of future deaths’ (PFD) report in relation to Amy’s death. She identified:
• Staffing levels: inadequate staffing levels which prevented Amy from receiving the one-to-one time required in her care plan;
• Risk assessment: the Priory’s failure to adequately complete risk assessments concerning Amy or, since her death, to address shortcomings in its risk assessment processes;
• Information sharing: a lack of information sharing in relation to Amy amongst staff and a policy that continues to lack clear instructions on information recording processes;
• Emergency procedures: following the insufficient emergency response when Amy was found with a ligature around her neck, a continuing lack of Advanced Life Support Training of any staff on site to enable them to respond to emergency situations.
Amy’s mother Tania El-Keria said: “We buried Amy four years ago this week. I want this report to lead to concrete action so that other young lives are not lost in the mental health system.”
Deborah Coles, director of INQUEST, said: “Amy was failed by a mental health system that placed her far from home in a private unit operating dangerous and grossly inadequate systems of care. That there remains no single body for recording the deaths of children as mental health in-patients and no requirement for independent investigations following such deaths is a national scandal.
“The CQC report earlier this week exposed the shameful culture of denial and secrecy surrounding deaths in the care of the NHS – a culture equally endemic amongst private providers, who are not subject to the same levels of scrutiny and accountability as public sector providers.
“Only an independent investigative framework – encompassing the private providers playing an increasing role in the provision of mental health services and services for those with learning disabilities – can tackle the dangerous systems and practises that are costing people’s lives.”
The family’s solicitor Tony Murphy said: “The family has also learned this week that the Health and Safety Executive is only now commencing its investigation into the concerning circumstances of Amy’s death, some four years later. This underlines the deeply defective system for investigating deaths in psychiatric hospitals.”
Notes to editors:
For further information, please contact Laura Smith at INQUEST on firstname.lastname@example.org or 020 7263 1111.
1. Amy had complex health needs arising from multiple mental health diagnoses. Despite being identified as at high risk of self harm and suicide using ligature, she was placed in a “dangerous” room with known high risk ligature points and left in possession of a large red football scarf, which she used as a ligature on the day she died. She had been in Ticehurst House for less than three months at the time of her death. It was her first admission to psychiatric hospital.
2. A jury at the inquest in June 2016 into Amy’s death returned a narrative questionnaire in which they found that Amy’s death had been contributed to by neglect. They also found that a number of failures had led to her death. The jury heard evidence of overstretched staff with insufficient time to meet the needs of the children on the unit; a high reliance on agency staff including those with no psychiatric experience; poor communication; and a lack of basic training.
3. HMC Penelope Schofield also highlighted the Department of Health’s failure to develop national guidance on staffing levels of inpatient CAMHS and the continuing shortage of acute mental health beds for young people close to where they live. Ticehurst House was a two-hour drive from Amy’s family home in Hounslow, west London. Copies of the ‘prevention of future deaths’ report have been provided to the Priory Group and Hounslow Borough Council, which was criticised for failing to support Amy’s family following her placement so far from home.
4. Amy is one of at least 11 children who have died as mental health in-patients between 2010 and 2014 that INQUEST has identified through our casework and an extensive FOI exercise. The true number of deaths from this period is likely to be higher as many bodies either refused to provide data or responded that they did not hold the information requested.
5. Approximately 47 per cent of all in-patient child and adolescent mental health services are now run by private providers, including the Priory Group.
INQUEST provides specialist advice on deaths in custody or detention or involving state failures in England and Wales. This includes a death in prison, in police custody or following police contact, in immigration detention or psychiatric care. INQUEST's policy and parliamentary work is informed by its casework and we work to ensure that the collective experiences of bereaved people underpin that work. Its overall aim is to secure an investigative process that treats bereaved families with dignity and respect; ensures accountability and disseminates the lessons learned from the investigation process in order to prevent further deaths.
Please refer to INQUEST the organisation in all capital letters in order to distinguish it from the legal hearing.
‘I was already working with INQUEST, which is the organisation who monitor deaths in custody, and at one AGM I told the audience that what happened to these people [killed in police custody like Chistopher Alder, Roger Sylvester and many others] could happen to any of us. And then a couple of years later, I was standing in front of them again but now it had happened to my cousin. So my family and me were now “users” of Inquest. It shows you that none of us are immune – here am I, Benjamin Zephaniah, patron of INQUEST and client of INQUEST at the same time.’
– Benjamin Zephaniah