Before HM Assistant Coroner Ian Wade KC
Beaconsfield Coroner’s Court
29 Windsor End, Beaconsfield, HP9 2JJ
4-14 August 2025
Ruth was just 14 years old when she died by self inflicted means whilst detained under the Mental Health Act on Thames ward, a Psychiatric Intensive Care Unit (PICU) at Huntercombe Hospital Maidenhead (run by Active Care Group). Now an inquest jury has concluded that Ruth was unlawfully killed and that multiple failings in her care contributed to her death.
Ruth had been transferred to Thames ward on 4 October 2021, two hours’ from her family home. The transfer went ahead despite her parents repeatedly raising serious concerns about the appropriateness of the placement not least because of CQC reports highlighting issues around patient safety at the hospital including around inadequate staffing and the training of staff. The inquest heard that on first seeing Ruth after she arrived on Thames ward, her treating psychiatrist immediately felt it was not the right place for her, and within a few weeks had made a formal request for her transfer out to a less restrictive environment. His request was refused by commissioners.
Ruth’s detention under the Mental Health Act was for treatment of her diagnosed eating disorder. That treatment had included food exposure, however once transferred to Thames Ward she was not shown any food until over six weeks after her admission, and then only in response to concerns raised by her mother. The inquest heard that the lack of treatment provided also extended to a lack of treatment by the Clinical Psychologist, whose work with Ruth should have been directed at understanding the reasons for Ruth’s eating disorder. Ruth only had two sessions with the clinical psychologist in the last 3 months of her life. In addition Ruth did not have access to any family therapy even though this was recognised as a central part of her treatment. Ruth’s parents repeatedly raised concerns about the lack of therapy Ruth was receiving but no action was taken. Ruth’s parents also raised concerns about Ruth’s unrestricted access to her mobile phone but these were not acted upon and evidence at the inquest revealed that she repeatedly accessed harmful material.
Prior to her admission, Ruth had been supported daily by her family who were present with her almost continuously whilst she received inpatient treatment on a general paediatric ward. Due to a blanket policy applied by Huntercombe Hospital, as soon as Ruth was transferred to Thames ward, she was initially only permitted to see her parents twice a week for one hour. Despite her parents pleading for more contact with her, the visits were only increased to twice a week for two hours. During their evidence, Ruth’s parents described feeling that she was being punished and not helped or supported.
On 12 February, Ruth was supposed to be constantly observed. Just 6 days earlier she had been found to have seriously self-harmed when her levels of observation had not been adhered to. Despite this, on 12 February Ruth was again left on her own for approximately 15 minutes during which time, she walked across the ward, past several members of staff, entered her room, closed her door and fatally self harmed.
The inquest heard evidence that ward staff had repeatedly raised concerns with managers about understaffing prior to Ruth’s death and did so again on 12 February when the ward was significantly understaffed. Staff gave evidence that they did not have enough staff to “safely run the shift”. The support worker who was supposed to be observing Ruth when she died was employed by Platinum Agency, a staffing agency whose Director was also a nurse at the hospital. He had never worked in a hospital before and had completed online training, which was not specific to working in a mental health setting, or working with children. The 12 February was his first ever shift in a hospital. He did not receive the required induction once on the ward, which should have led to his shift being cancelled. Despite no induction he was permitted to work on the ward, and was within hours was allocated to observe patients on a 1:1 basis.
In a note that Ruth left, she described the “non-existent therapy that happens here, the unsafe number of staff, the month long stays and how the place makes you ten times worse than when you came”.
The jury concluded that Ruth died by unlawful killing. They found that the following failures and inadequacies contributed to her death.
- Ruth was provided with insufficient therapy.
- Family visits were limited despite family interaction being identified as an integral part of improving Ruth’s mental wellbeing.
- Ruth’s parents were not given adequate information about care options, the appeal process and refusal rights.
- Ruth’s care pathway was insufficient to allow her to improve towards discharge.
- Training provided to agency staff was not in accordance with policy.
- Ruth was not prevented from accessing items with which she could self-harm.
- Ruth was not prevented from accessing harmful material on the internet.
Ruth’s parents said: “There is an empty space at our table, a silent bedroom in our home, a gaping hole in our family that will never be filled. We should be getting ready to celebrate Ruth’s 18th birthday in a few weeks’ time. She was just 14 when she died, now 3 ½ years ago. Ruth was an incredible, bright, friendly, loving and adventurous girl with a whole life of joy ahead of her. She, like many other teenagers, developed an eating disorder. When, at our most vulnerable as a family, we reached out for help; we ultimately found ourselves trapped in a system that was meant to care for her, to help her, to keep her safe, but instead locked her away and harmed her. The inquest has been a harrowing and traumatic process for us, not just in reliving the awful reality of her neglect, but also bringing to light even more than we had feared at the time.
Over the last two weeks, we have heard about the numerous systemic failures at Huntercombe Hospital. It would be easy to be distracted by the failings of one individual. However shocking that conduct might have been, it is paramount that the other wider and more important issues are acknowledged and addressed”
Read the full statement made by Ruth’s parents
Jodie Anderson, senior caseworker at INQUEST, said: “The jury’s findings are a stark indictment of a mental health system that sent a vulnerable child far from home to a private unit with dangerously inadequate care. The failings exposed during this inquest reveal a system that is shamefully neglecting its duty to protect children.
We must urgently confront the privatisation of children’s mental health, where professional inertia and a lack of accountability continue to place young lives at risk.
While catastrophic individual failings in Ruth’s care have been highlighted, the jury rightly recognised the wider systemic failures at Huntercombe. These are not isolated issues - they reflect a national crisis in children’s mental health services. Until we address this broken system, more children like Ruth will die, still searching for the support they so desperately need."
ENDS
NOTES TO EDITORS
For further information and to note your interest, please contact Leila Hagmann on leilahagmann@inquest.org.uk.
The family are represented by INQUEST Lawyers Group members Charlotte Haworth Hird of Bhatt Murphy and Tim Moloney KC and Alison Seaman of Doughty Street Chambers. They are supported by INQUEST Senior Caseworker Jodie Anderson.
Other Interested persons represented are Active Care Group (formerly the Huntercombe Group) and Oxford Health NHS Foundation Trust.
Taplow Manor (formerly Huntercombe Hospital Maidenhead) has been subject to a series of media investigations over allegations of ‘systemic abuse'.
Journalists should refer to the Samaritans Media Guidelines for reporting suicide and self-harm and guidance for reporting on inquests.
Surname pronounciation: Shih-man-KIEH-vich
Ruth's family are campaigning for vital changes to the Mental Health Bill to safeguard children and young people. They are calling for:
- Parental involvement in care - protecting and strengthening children’s rights to unrestricted family contact.
- Safeguarding against children being placed in inappropriate settings, such as adult wards or far from home.
- Increased community-based support to tackle inequalities and prevent unnecessary hospitalisation.
Write to your MP to support these amendments
Ruth Szymankiewicz
CONTENT WARNING: Please read with care as this page may involve information on death, suicide, mental illness, disability, state neglect, and police and prison violence that some people may find upsetting. If you need support, please visit our support page.
Before HM Assistant Coroner Ian Wade KC
Beaconsfield Coroner’s Court
29 Windsor End, Beaconsfield, HP9 2JJ
4-14 August 2025
Ruth was just 14 years old when she died by self inflicted means whilst detained under the Mental Health Act on Thames ward, a Psychiatric Intensive Care Unit (PICU) at Huntercombe Hospital Maidenhead (run by Active Care Group). Now an inquest jury has concluded that Ruth was unlawfully killed and that multiple failings in her care contributed to her death.
Ruth had been transferred to Thames ward on 4 October 2021, two hours’ from her family home. The transfer went ahead despite her parents repeatedly raising serious concerns about the appropriateness of the placement not least because of CQC reports highlighting issues around patient safety at the hospital including around inadequate staffing and the training of staff. The inquest heard that on first seeing Ruth after she arrived on Thames ward, her treating psychiatrist immediately felt it was not the right place for her, and within a few weeks had made a formal request for her transfer out to a less restrictive environment. His request was refused by commissioners.
Ruth’s detention under the Mental Health Act was for treatment of her diagnosed eating disorder. That treatment had included food exposure, however once transferred to Thames Ward she was not shown any food until over six weeks after her admission, and then only in response to concerns raised by her mother. The inquest heard that the lack of treatment provided also extended to a lack of treatment by the Clinical Psychologist, whose work with Ruth should have been directed at understanding the reasons for Ruth’s eating disorder. Ruth only had two sessions with the clinical psychologist in the last 3 months of her life. In addition Ruth did not have access to any family therapy even though this was recognised as a central part of her treatment. Ruth’s parents repeatedly raised concerns about the lack of therapy Ruth was receiving but no action was taken. Ruth’s parents also raised concerns about Ruth’s unrestricted access to her mobile phone but these were not acted upon and evidence at the inquest revealed that she repeatedly accessed harmful material.
Prior to her admission, Ruth had been supported daily by her family who were present with her almost continuously whilst she received inpatient treatment on a general paediatric ward. Due to a blanket policy applied by Huntercombe Hospital, as soon as Ruth was transferred to Thames ward, she was initially only permitted to see her parents twice a week for one hour. Despite her parents pleading for more contact with her, the visits were only increased to twice a week for two hours. During their evidence, Ruth’s parents described feeling that she was being punished and not helped or supported.
On 12 February, Ruth was supposed to be constantly observed. Just 6 days earlier she had been found to have seriously self-harmed when her levels of observation had not been adhered to. Despite this, on 12 February Ruth was again left on her own for approximately 15 minutes during which time, she walked across the ward, past several members of staff, entered her room, closed her door and fatally self harmed.
The inquest heard evidence that ward staff had repeatedly raised concerns with managers about understaffing prior to Ruth’s death and did so again on 12 February when the ward was significantly understaffed. Staff gave evidence that they did not have enough staff to “safely run the shift”. The support worker who was supposed to be observing Ruth when she died was employed by Platinum Agency, a staffing agency whose Director was also a nurse at the hospital. He had never worked in a hospital before and had completed online training, which was not specific to working in a mental health setting, or working with children. The 12 February was his first ever shift in a hospital. He did not receive the required induction once on the ward, which should have led to his shift being cancelled. Despite no induction he was permitted to work on the ward, and was within hours was allocated to observe patients on a 1:1 basis.
In a note that Ruth left, she described the “non-existent therapy that happens here, the unsafe number of staff, the month long stays and how the place makes you ten times worse than when you came”.
The jury concluded that Ruth died by unlawful killing. They found that the following failures and inadequacies contributed to her death.
Ruth’s parents said: “There is an empty space at our table, a silent bedroom in our home, a gaping hole in our family that will never be filled. We should be getting ready to celebrate Ruth’s 18th birthday in a few weeks’ time. She was just 14 when she died, now 3 ½ years ago. Ruth was an incredible, bright, friendly, loving and adventurous girl with a whole life of joy ahead of her. She, like many other teenagers, developed an eating disorder. When, at our most vulnerable as a family, we reached out for help; we ultimately found ourselves trapped in a system that was meant to care for her, to help her, to keep her safe, but instead locked her away and harmed her. The inquest has been a harrowing and traumatic process for us, not just in reliving the awful reality of her neglect, but also bringing to light even more than we had feared at the time.
Over the last two weeks, we have heard about the numerous systemic failures at Huntercombe Hospital. It would be easy to be distracted by the failings of one individual. However shocking that conduct might have been, it is paramount that the other wider and more important issues are acknowledged and addressed”
Read the full statement made by Ruth’s parents
Jodie Anderson, senior caseworker at INQUEST, said: “The jury’s findings are a stark indictment of a mental health system that sent a vulnerable child far from home to a private unit with dangerously inadequate care. The failings exposed during this inquest reveal a system that is shamefully neglecting its duty to protect children.
We must urgently confront the privatisation of children’s mental health, where professional inertia and a lack of accountability continue to place young lives at risk.
While catastrophic individual failings in Ruth’s care have been highlighted, the jury rightly recognised the wider systemic failures at Huntercombe. These are not isolated issues - they reflect a national crisis in children’s mental health services. Until we address this broken system, more children like Ruth will die, still searching for the support they so desperately need."
ENDS
NOTES TO EDITORS
For further information and to note your interest, please contact Leila Hagmann on leilahagmann@inquest.org.uk.
The family are represented by INQUEST Lawyers Group members Charlotte Haworth Hird of Bhatt Murphy and Tim Moloney KC and Alison Seaman of Doughty Street Chambers. They are supported by INQUEST Senior Caseworker Jodie Anderson.
Other Interested persons represented are Active Care Group (formerly the Huntercombe Group) and Oxford Health NHS Foundation Trust.
Taplow Manor (formerly Huntercombe Hospital Maidenhead) has been subject to a series of media investigations over allegations of ‘systemic abuse'.
Journalists should refer to the Samaritans Media Guidelines for reporting suicide and self-harm and guidance for reporting on inquests.
Surname pronounciation: Shih-man-KIEH-vich
Ruth's family are campaigning for vital changes to the Mental Health Bill to safeguard children and young people. They are calling for:
Write to your MP to support these amendments
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