Tia Wilson

Before Assistant Coroner David Manknell KC
Southwark Coroner’s Court
28 October - 6 November 2024

Tia Wilson, 18, died on 21 August 2021 whilst detained under the Mental Health Act at Maudsley Hospital.

Tia had a warm and beautiful personality. She was cool, creative and very intelligent. She would light up every room that she entered.

She was incredibly talented and someone who was naturally gifted at so many things including singing, music, drawing, nails, hair and sports.

At school, you would often find her in the music room, with her headphones on listening to music. There was nothing that she couldn’t do if she applied her mind to it as she had such strength and determination.

She had a brilliant sense of humour, a beautiful smile and an infectious laugh. She had a natural ability to connect and could always see the best in people.

Her friends described her as “someone who loved us, looked out for us, put our needs before hers and was always there when we called”. She was caring, loving, supportive, trustworthy, thoughtful and loyal.

Tia was admitted to Maudsley Hospital on 10 August 2021 following a deterioration in her mental well-being and two significant self-harming incidents involving ligatures.

This was Tia’s first admission to a mental health hospital.

Within hours of her arrival at hospital, Tia was placed on constant observations due to her risk and these continued for the first seven days of her admission.

Tia’s observations were reduced to intermittent 15-minute observations on 17 August yet there was no record of the reasons for this decision or who it was made by.

There were two significant incidents on the ward on 17 and 19 August 2021 during which Tia was restrained and forcibly medicated due to her level of agitation.

The inquest heard evidence that Tia’s level of observations should have been increased to constant observations following these incidents, but they were not.

On the morning of her death, Tia was described as very low and very tearful. She was observed pacing the ward, kicking doors and asking to leave. Despite this, no steps were taken to review Tia’s risk or increase her level of observations.

The evidence at the inquest revealed that Tia was by this time being observed on an hourly basis, checks which were described by one witness as ‘a head count’.

There was no record that Tia’s observation level had in fact been reduced from every 15 minutes to hourly, yet staff were only checking her whereabouts every hour.

At lunchtime on 21 August, Tia could not be located on the ward. Following a search by staff, she was found unresponsive in the ward bathroom having ligatured and was pronounced dead shortly after. 

Now an inquest has found that there were multiple failures in the way staff managed her risks which contributed to Tia’s death including:

1. A failure to record decisions regarding changes to Tia’s levels of observations and to ensure that all staff were aware of how frequently Tia should have been observed.
2. A failure to increase Tia’s level of observations to enhanced 1:1 observations on 17 and 19 August 2021.
3. That insufficient efforts were made by the Trust to ensure that staff had an adequate understanding of the level of risk Tia posed to herself on 21 August.
4. That staff failed to implement agreed observation levels on the day of Tia’s death.
5. That there was a failure to ensure sufficient staff were present to provide the necessary level of supervision and observation of Tia between 11am and 1pm on the day of her death.

Sharon Wilson, Tia’s mother said: “Losing Tia has caused immeasurable pain to me and her family and friends. I knew I couldn’t stop her harming herself again, so I wanted her to be somewhere safe.

I kept being told that she was “fine” but I now know that she couldn’t have been further away from that.

Even though Tia was only 18, she was on an adult ward surrounded by people who were very unwell and much older than her.

That must have been a very scary environment for her, and I did not hear any evidence that any member of staff properly considered Tia’s additional vulnerability due to her age.

I am grateful to the jury for recognising the failings in Tia’s care and I am thankful that South London and Maudsley have finally accepted some of those failings, although I do not know why it has taken them over three years to do so”. 

Selen Cavcav, Senior Caseworker at INQUEST, said: “No one, not least an 18-year-old teenager should die in a healthcare setting designed to keep people safe. 

What Tia needed was care in an age appropriate and therapeutic environment, delivered by staff who were adequately trained to manage her complex needs.

What she received, instead, was an environment that was chaotic, unsafe, and fundamentally ill-equipped to meet her needs. 

These systemic failures are not new but part of a troubling pattern within South London and Maudsley NHS Trust (SLAM).

The question is no longer whether these issues exist—it's why despite repeated recommendations and damning inquest findings, they have been allowed to continue for so long.”

ENDS

NOTES TO EDITORS

For further information, interview requests and to note your interest, please contact Leila Hagmann on 020 7263 1111 or [email protected].

The family is represented by INQUEST Lawyers Group members Charlotte Haworth Hird of Bhatt Murphy Solicitors and Alison Gerry of Doughty Street Chambers.  The family are supported by Inquest Senior Caseworker Selen Cavcav.

Other Interested persons represented are South London and Maudsley NHS Foundation Trust (SLAM)

Journalists should refer to the Samaritans Media Guidelines for reporting suicide and self-harm and guidance for reporting on inquests.

PREVIOUS INQUESTS INVOLVING SLAM:

Since 2014, INQUEST has worked on at least 39 deaths involving SLAM. These include: 

• Kenan Canalp, 27, died whilst detained in Maudsley Hospital on 8 March 2018. An inquest found that neglect and serious failures by SLaM contributed to his death. Media release. 
• Agnes McDonald, 41, died after walking out of Ladywell mental health unit, run by SLAM. She had been admitted to the unit as a non-sectioned patient just three weeks before her death. Media release.
• Christopher Brennan, 15, died after calling for emergency help at Bethlem hospital (under the care of SLAM) after he had attempted suicide by swallowing objects. An inquest found neglect contributed to Chris' death. Media relase.