This is a media release by Hudgells Solicitors, reshared by INQUEST
The mother of a 12-year-old girl who took her own life in a mental health facility – where she had been sectioned to after hospital doctors failed to identify a treatable brain condition – says it has been ‘devastating to hear how she was failed’ by health services.
Mia Lucas, of Nottingham, took her own life at the Becton Centre for Children and Young People in Sheffield in January last year, just weeks after she had been sectioned under the Mental Health Act.
An inquest has now cast doubt over the merit of the decision to section Mia, as she was found to have been suffering from autoimmune encephalitis, an inflammation of the brain that can cause extreme psychiatric symptoms.
It is a condition that can be treated in a hospital setting.
Hospital failed to identify condition
Mia’s family had initially taken her to A&E at Queens Medical Centre (QMC) in Nottingham on New Year’s Eve, 2023, when she became physically aggressive towards her mother Chloe, attempting to access and use knives.
Prior to this, Mia had been suffering from increasing sudden mood swings, extreme emotional outbursts and been physically aggressive throughout December.
A two-week inquest into her death, at the Medico-Legal Centre in Sheffield, heard how she had been hearing voices, telling her she needed to go to heaven or something would happen to her relatives, and she was hallucinating.
Mia had an MRI scan and blood test at the Queens Medical Centre but as doctors decided there was no underlying physical cause of her psychosis, she was sectioned under the Mental Health Act on January 4th, 2024 and then transferred to the Becton Centre on January 9th.
She was in the facility just three weeks before taking her own life in her room. In that time, she made four other attempts at taking her own life, on each occasion using items from her room.
Blood tests confirmed treatable brain condition
The inquest into Mia’s death this week heard from pathologist Professor Marta Cohen, who confirmed that recent blood tests had conclusively proved that Mia had been suffering from autoimmune encephalitis. She said that had caused her psychosis, leading to Mia taking her own life.
Consultant paediatric neurologist, Dr Michael Taylor, who conducted an independent review of the evidence for HM Senior Coroner Tanyka Rawden, also told the hearing he would have liked to have seen a fluid test, through a lumbar puncture, and a brain wave scan, called an EEG, conducted on Mia when she was at the Queens Medical Centre, before she was sent into mental health care.
Numerous failings in Mia’s treatment and care at the Becton Centre were also identified as part of a Sheffield Children’s NHS Foundation Trust investigation.
These included observations of Mia not being carried out in line with policies, observation charts which were ‘not fit for purpose’ and poor communication between staff on shift handovers, meaning details of incidents of concern involving Mia were not passed on.
‘Failures possibly contributed to death’
An inquest jury returned a narrative verdict, in which they said the failure to undertake a lumbar puncture possibly contributed to Mia’s death, as ‘potential indicators of autoimmune encephalitis were missed.’
They added that information provided to the Becton Centre when she was transferred lacked sufficient detail and provided an ‘inappropriate level of assurance that organic causes had been ruled out’
At the Becton Centre, the jury said insufficiently robust communication and management of risk led to them failing to respond adequately to Mia’s risk of self-harm.
Senior Coroner Tanyka Rawden, who described Mia as a ‘little girl with huge heart and huge personality’, said she would be sending a Prevention of Future Deaths Report to the Health Secretary, The Royal College of Paediatrics and Child Health, and the Royal College of Psychiatry, as she has concerns over there being no current national guidelines around autoimmune encephalitis, which could lead to it not being identified in more cases.
Speaking after the inquest concluded, Mia’s mother Chloe Hayes said:“These past two weeks have been, at times, unbearable, sitting and listening to how Mia was failed.
“It has been devastating to listen to how, when she needed specialist healthcare, for the first time in her life, she was so badly let down.
She was let down at the Queen’s Medical Centre in Nottingham. I believe they simply dismissed her and looked to pass her onto mental health services as quickly as possible.
She was sectioned to a facility which was completely unsuitable for her, and one which failed to keep her safe. Her mental health spiralled deeper out of control, as she was not being treated for her condition.
I have never believed for a moment that Mia ever wanted to take her own life. She was always a happy, healthy child and had so much to live for.
Mia’s medical cause of death changing now, nearly two years after her passing, is heartbreaking, but also shows the failures and the fight we’ve had to endure.
My beautiful little girl has lost her life and I will never forgive the Queen’s Medical Centre or the Becton Centre for failing her.
I will never recover from what happened to Mia and I’ll continue to fight for full accountability and justice for Mia being denied the amazing life I know she would have gone on to enjoy.”
Solicitor Amy Rossall, of Hudgell Solicitors, represents Chloe and said: “As we have heard at this Inquest, in the final weeks of her life, Mia was suffering from a potentially treatable inflammation of the brain that can cause extreme psychiatric symptoms.
It means she was wrongly sectioned under the Mental Health Act at the Queen’s Medical Centre in Nottingham, which should have carried out further investigations than the blood test and MRI scan which was performed before Mia was transferred to the Becton Centre.
Had a fluid test through a lumbar puncture being taken, and a brain wave scan, her condition may have been identified and treated successfully.
We’ve heard many comments about lessons being learned as a result of what happened to Mia, and those learnings will hopefully help to avoid other families losing their children to the condition, as they will hopefully receive the required testing and treatment in hospital that they need.
Nothing however can change the impact on Mia and her loved ones. Mia lost her life; her family lost a beautiful girl.
When they needed specialist healthcare support, it failed, both at Queen’s Medical Centre, and at the Becton Centre, where numerous failings to properly observe and protect Mia from self-harm, alongside poor communication between staff have been identified.
We will continue to support Chloe in seeking full justice and accountability.”
Afterwards, Mia's mother Chloe saidthat she has agreed for Mia’s samples, which were frozen after her death, to be used for further research and educational purposes.
She also said she wanted Mia to be remembered as the ‘happy, fun, friendly’ girl she was before she was taken ill.
“For the past two weeks the world has seen many pictures of my beautiful little girl in the media; pictures which have shown exactly the kind of girl she was, a happy, fun, friendly girl who had so much to live for,” she said.
“Her illness led to a sudden change in her character and behaviour. We want everyone to know that Mia was like this only for the final few weeks of her life, when she was seriously ill, and that is why we sought specialist help for her.
“For the other 12 years, she was a beautiful soul who loved life and loved her family, and that’s how we want her to be remembered.
“She was unwell for such a short period of her life. Not for a second do I believe she intended to take her life; she was ill and not in control of her own thoughts. It was a quick decision she made without thinking rationally.
“She didn’t need to die, and with the right care and treatment, she could have got better. It may have taken time, but I fully believe she’d still be with us today had she been properly cared for, and she would have had such a great life to look forward to.
"We were so close as a mother and daughter, we are all heartbroken beyond words."
You can read Chloe's full statement here.
ENDS
Notes for Editors
For more information, please call Paul Baxter on 07944 535044.
Mia Lucas
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This is a media release by Hudgells Solicitors, reshared by INQUEST
The mother of a 12-year-old girl who took her own life in a mental health facility – where she had been sectioned to after hospital doctors failed to identify a treatable brain condition – says it has been ‘devastating to hear how she was failed’ by health services.
Mia Lucas, of Nottingham, took her own life at the Becton Centre for Children and Young People in Sheffield in January last year, just weeks after she had been sectioned under the Mental Health Act.
An inquest has now cast doubt over the merit of the decision to section Mia, as she was found to have been suffering from autoimmune encephalitis, an inflammation of the brain that can cause extreme psychiatric symptoms.
It is a condition that can be treated in a hospital setting.
Hospital failed to identify condition
Mia’s family had initially taken her to A&E at Queens Medical Centre (QMC) in Nottingham on New Year’s Eve, 2023, when she became physically aggressive towards her mother Chloe, attempting to access and use knives.
Prior to this, Mia had been suffering from increasing sudden mood swings, extreme emotional outbursts and been physically aggressive throughout December.
A two-week inquest into her death, at the Medico-Legal Centre in Sheffield, heard how she had been hearing voices, telling her she needed to go to heaven or something would happen to her relatives, and she was hallucinating.
Mia had an MRI scan and blood test at the Queens Medical Centre but as doctors decided there was no underlying physical cause of her psychosis, she was sectioned under the Mental Health Act on January 4th, 2024 and then transferred to the Becton Centre on January 9th.
She was in the facility just three weeks before taking her own life in her room. In that time, she made four other attempts at taking her own life, on each occasion using items from her room.
Blood tests confirmed treatable brain condition
The inquest into Mia’s death this week heard from pathologist Professor Marta Cohen, who confirmed that recent blood tests had conclusively proved that Mia had been suffering from autoimmune encephalitis. She said that had caused her psychosis, leading to Mia taking her own life.
Consultant paediatric neurologist, Dr Michael Taylor, who conducted an independent review of the evidence for HM Senior Coroner Tanyka Rawden, also told the hearing he would have liked to have seen a fluid test, through a lumbar puncture, and a brain wave scan, called an EEG, conducted on Mia when she was at the Queens Medical Centre, before she was sent into mental health care.
Numerous failings in Mia’s treatment and care at the Becton Centre were also identified as part of a Sheffield Children’s NHS Foundation Trust investigation.
These included observations of Mia not being carried out in line with policies, observation charts which were ‘not fit for purpose’ and poor communication between staff on shift handovers, meaning details of incidents of concern involving Mia were not passed on.
‘Failures possibly contributed to death’
An inquest jury returned a narrative verdict, in which they said the failure to undertake a lumbar puncture possibly contributed to Mia’s death, as ‘potential indicators of autoimmune encephalitis were missed.’
They added that information provided to the Becton Centre when she was transferred lacked sufficient detail and provided an ‘inappropriate level of assurance that organic causes had been ruled out’
At the Becton Centre, the jury said insufficiently robust communication and management of risk led to them failing to respond adequately to Mia’s risk of self-harm.
Senior Coroner Tanyka Rawden, who described Mia as a ‘little girl with huge heart and huge personality’, said she would be sending a Prevention of Future Deaths Report to the Health Secretary, The Royal College of Paediatrics and Child Health, and the Royal College of Psychiatry, as she has concerns over there being no current national guidelines around autoimmune encephalitis, which could lead to it not being identified in more cases.
Speaking after the inquest concluded, Mia’s mother Chloe Hayes said:“These past two weeks have been, at times, unbearable, sitting and listening to how Mia was failed.
“It has been devastating to listen to how, when she needed specialist healthcare, for the first time in her life, she was so badly let down.
She was let down at the Queen’s Medical Centre in Nottingham. I believe they simply dismissed her and looked to pass her onto mental health services as quickly as possible.
She was sectioned to a facility which was completely unsuitable for her, and one which failed to keep her safe. Her mental health spiralled deeper out of control, as she was not being treated for her condition.
I have never believed for a moment that Mia ever wanted to take her own life. She was always a happy, healthy child and had so much to live for.
Mia’s medical cause of death changing now, nearly two years after her passing, is heartbreaking, but also shows the failures and the fight we’ve had to endure.
My beautiful little girl has lost her life and I will never forgive the Queen’s Medical Centre or the Becton Centre for failing her.
I will never recover from what happened to Mia and I’ll continue to fight for full accountability and justice for Mia being denied the amazing life I know she would have gone on to enjoy.”
Solicitor Amy Rossall, of Hudgell Solicitors, represents Chloe and said: “As we have heard at this Inquest, in the final weeks of her life, Mia was suffering from a potentially treatable inflammation of the brain that can cause extreme psychiatric symptoms.
It means she was wrongly sectioned under the Mental Health Act at the Queen’s Medical Centre in Nottingham, which should have carried out further investigations than the blood test and MRI scan which was performed before Mia was transferred to the Becton Centre.
Had a fluid test through a lumbar puncture being taken, and a brain wave scan, her condition may have been identified and treated successfully.
We’ve heard many comments about lessons being learned as a result of what happened to Mia, and those learnings will hopefully help to avoid other families losing their children to the condition, as they will hopefully receive the required testing and treatment in hospital that they need.
Nothing however can change the impact on Mia and her loved ones. Mia lost her life; her family lost a beautiful girl.
When they needed specialist healthcare support, it failed, both at Queen’s Medical Centre, and at the Becton Centre, where numerous failings to properly observe and protect Mia from self-harm, alongside poor communication between staff have been identified.
We will continue to support Chloe in seeking full justice and accountability.”
Afterwards, Mia's mother Chloe saidthat she has agreed for Mia’s samples, which were frozen after her death, to be used for further research and educational purposes.
She also said she wanted Mia to be remembered as the ‘happy, fun, friendly’ girl she was before she was taken ill.
“For the past two weeks the world has seen many pictures of my beautiful little girl in the media; pictures which have shown exactly the kind of girl she was, a happy, fun, friendly girl who had so much to live for,” she said.
“Her illness led to a sudden change in her character and behaviour. We want everyone to know that Mia was like this only for the final few weeks of her life, when she was seriously ill, and that is why we sought specialist help for her.
“For the other 12 years, she was a beautiful soul who loved life and loved her family, and that’s how we want her to be remembered.
“She was unwell for such a short period of her life. Not for a second do I believe she intended to take her life; she was ill and not in control of her own thoughts. It was a quick decision she made without thinking rationally.
“She didn’t need to die, and with the right care and treatment, she could have got better. It may have taken time, but I fully believe she’d still be with us today had she been properly cared for, and she would have had such a great life to look forward to.
"We were so close as a mother and daughter, we are all heartbroken beyond words."
You can read Chloe's full statement here.
ENDS
Notes for Editors
For more information, please call Paul Baxter on 07944 535044.
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