Concern over mental health beds after death of Ipswich teen

Madeleine Savory, who identified as non-binary and used they/them pronouns, was admitted to the Bergholt Ward, a paediatric ward at East Suffolk and North Essex NHS Foundation Trust (ESNFT) run Ipswich Hospital, on February 3, 2022, after they absconded from school and self-harmed.

They were placed on a list for a 'tier 4' bed in a mental health unit on February 7 but, on February 19, they made an attempt on their life while in the ward toilet, and died on February 26.

Madeleine had a five-month history of self-harm, low mood, food restriction and gender dysphoria and had been under the care of Norfolk & Suffolk NHS Foundation Trust (NSFT) after a hospital admission in September 2021.

They had been on the ward for 12 days before the attempt on their own life, and the average wait for a mental health bed in February 2022 was around 46 days.

During an inquest, which took place in August, coroner Darren Stewart said the lack of appropriate resources surrounding mental health beds may have contributed to Madeleine's death, although he found the East of England Provider Collaborative (EEPC) who manage bed allocation in the area were "diligent" and did everything they could at the time. 

On Tuesday October 17, during a Prevention of Future Deaths hearing at Suffolk Coroner's Court, Mr Stewart said he will be issuing a report to the Secretary of State for Health and Social Care outlining his concerns for mental health bed allocation nationally. 

Mr Stewart said he will be issuing a report to the Secretary of State for Health and Social Care, Steve Barclay (pictured), outlining his concerns for mental health bed allocation nationally.

While he said the EEPC has introduced several measures, including a review of bed configuration, the implementation of shot-term pathways and enhancing the workforce, all of which he welcomed, he said many of the factors that impact their effectiveness were controlled at a national level.

"Although regionally the EEPC, and indeed others across the country, may have introduced measures to mitigate and reduce, where possible, waiting times, it remains that those mental health patients who are the most vulnerable within our community, children and young people, face waiting lists and delays in accessing appropriate care," he said. 

"Earlier allocation of these facilities to children and young people will prevent future deaths and may have prevented in Madeleine's case her very sad death." 

The headteacher of Northgate High School said Madie's death had been felt across the school community.

During the inquest, Mr Stewart identified failings in the care of Madeleine at Northgate High School, where they were a pupil. 

The court heard evidence that Madeleine, whose whereabouts was meant to be monitored while on the school premises, was absent for a total of 110 minutes on February 3 before teachers were alerted by their school friends. 

A supply teacher was covering Madeleine's lesson that day, and the court heard supply staff at the school would not be informed about specific care plans for children due to a previous GDPR incident. 

Madeleine being unaccounted for was also missed by two absence officers who, due to a misunderstanding, only realised they weren't present around the same time their friends informed a teacher.

On Tuesday, Mr Stewart said the school had implemented several new strategies including additional staff for attendance monitoring and double checks, which he said he was "satisfied" would provide a safer environment for pupils. 

In evidence throughout the inquest, the court was told staff on the Bergholt Ward had not fully checked Madeleine's records due to time pressures, and one nurse involved in their care said she was 'learning on the job' when it came to treating mental health patients. 

Mr Stewart highlighted failures of staff not understanding Madeleine's risks including ongoing failures to conduct risk assessments, as well as failures to ensure relevant information was communicated to all staff involved in their care.

However, on Tuesday he found the ward had implemented several new measures including the employment of two full-time paediatric mental health nurses, a risk assessment overhaul and further documentation to ensure all staff are aware of risks. 

Further liaison, including multi-agency meetings, between NSFT and ESNFT have also been facilitated, and Mr Stewart said he was satisfied that these measures would enable the trust to provide appropriate care for children with mental health issues. 

He also found NSFT had introduced further crisis provision, more staff training and the provision of specialist mental health support for the acute setting.