A senior coroner said we were “failing” our young people after a teenager was denied a face-to-face meeting before committing suicide during a blockade.
Penelope Schofield warned that there was an “obvious risk” that young people would succumb to mental illness if no urgent action was taken, as she said she had written to Sajid Javid, the health minister.
The medical examiner concluded that 14-year-old Robin Skilton committed suicide after being disappointed by “gross failures” in the NHS.
The setbacks were so severe in the case of the suicidal teenager – who was constantly denied evaluation – that Ms Schofield ruled that the NHS was guilty of “neglect”.
Robin from Horsham in West Sussex disappeared from his family home for 670,000 British pounds and hanged himself in a park on May 7 last year, having a long history of self-harm and expressing a desire to take his own life.
At the time, England was in the second step of the government’s route map outside the blockade, and no indoor mixing between different households was allowed.
Despite “real serious concerns” about her mental health, Robin did not receive face-to-face counseling, was not examined by a child psychiatrist or assessed for mental health problems, and was discharged from the NHS a month before her suicide, although she was was on its high-risk “red list.”
It was targeted at a council support program, but was kept on a waiting list for an individual consultation for ten months.
After all, when she had a consultation, it was just a remote session because of the pandemic.
Robin’s father, Alan Skilton, the director of a software company, kept asking the authorities for help.
“Amazing” lack of care
He told his daughter’s investigation that the lack of care she received was “amazing.”
Ms Schofield, who has chaired a number of high-profile investigations, including the Shoreham Airshow crash, said she would write a report to the government after the hearing.
“As a society, we fail young people,” Ms. Schofield warned.
Ms Schofield said she was “shocked” to hear evidence during the two-day hearing that the number of young people seeking mental health care had risen by 95 per cent recently.
She said: “Trying to manage it without more resources means that we are not providing the help that young people need.
“Robin’s case is proof of that.
“It’s a clear risk that more lives will be lost if we don’t deal with it.
“Therefore, I will write a report on the prevention of future deaths to the Secretary of State for Health to address these concerns.”
Ms Schofield added that young people “need resources to get the help they need”.
Ms. Schofield ruled that there were “gross failures” by the Sussex NHS Foundation Trust in the case of Robin and the Sussex Trust’s Mental Health Office. [CAMHS].
“I have to come to a conclusion about neglect”
She said: “I appreciate the landscape in which the Trust works, as Covid-19 has increased the level of complexity, but there have been many gaps in the care provided to Robin.
“In my opinion, the combination of these failures means that I have to come to a conclusion of disregard. It was a gross failure to take care of someone in a dependent condition.
“Robin took his own life while struggling with his mental health.
“Robin’s mental health services failed because they did not recognize her deteriorating mental health, nor did they provide her with the necessary care.
“Neglect also contributed to her death.
Dr. Alison Wallis, the Trust’s clinical director of pediatric services, said through tears to Robin’s parents that “you didn’t get the service you deserved” and that Covid affected their care.
Ms. Schofield outlined the main shortcomings.
“We tried our best to help”
These include the failure of CAMHS to assess it “appropriately or at all”, which led to missed opportunities to meet its “escalating needs” for several years, but “especially in April 2021, when it was clear that there is a risk to life. “
Ms Schofield said there had been a failure to arrange face-to-face consultations, a lack of direct communication, a failure to offer treatment with CAMHS when she met his criteria, and a failure to “evaluate Robin at all times”.
She ruled that “the decision to discharge her from CAMHS and instead continue her treatment for autism was inappropriate” and that Robin should have seen a child psychiatrist.
Robin’s father, who attended the Chichester investigation with his wife and Robin’s mother, Victoria, said he “tried everything we could to help” the teenager.
He said: “We believe that if Robin had been seen correctly earlier … her mental health would have improved and she would not have committed suicide.
Robin was “sociable, sociable, and easy to make friends,” loved ballet, gymnastics, and swimming, was “naturally artistic,” and loved to sing and dance.
However, her problems began in late 2018, after she moved to Mallais School for all girls in Horsham a year earlier.
Hearing voices
Robin suffered mental health problems, repeatedly injured herself, attempted suicide and was admitted to hospital four times, later telling medics that she heard voices and saw images.
She was referred to the West Sussex County Youth Emotional Support Service and attended group sessions, but they did not support her and she was kept on a waiting list for an individual consultation for 10 months.
After all, when she had a consultation, it was not effective because it was remote because of the pandemic.
Initially, CAMHS would not take her, although it met her criteria, and when the service did, she focused on trying to assess her for autism.
Her parents were told that self-harm was a “coping mechanism,” that Robin did not receive review calls every two weeks, and that she did not speak directly to CAMHS.
Mr. Skilton was left “shocked” Robin received a questionnaire to fill out when she was suicidal and was left repeatedly disappointed that he was not kept in the dark by the authorities because of “confidentiality.”
“Our requests for assistance have been rejected”
“The hospital just seemed to be going through a bookmark exercise trying to get her discharged,” Mr Skilton said. “Even when she threatened to jump off a bridge, our requests for help were denied.”
Robin said “no one can help her” and that she “looks forward to ending her life.”
In early 2021, she was rushed to hospital for an attempted paracetamol overdose and stayed for three nights. Mr Skilton said: “We were surprised that after she tried to take her own life, she left the hospital with less support.
“No one seems to take her mental health seriously.”
Mr. and Mrs. Skilton were “desperate” for the lack of help Robin received near her death, asked CAMHS if she could be separated, and considered admitting her to the Priory for £ 1,300 a night.
Mr Skilton said in the days before her death that “her mood had changed completely” and this gave her parents “false hope”.
Missed opportunities
Lawyer Rebecca Agnew of the Sussex Partnership NHS Foundation Trust acknowledged that “CAMHS did not properly assess Robin, leading to missed opportunities for her escalating needs.”
She added: “The trust is officially apologizing to its parents for these omissions.
“The Trust did not adequately assess Robin and did not provide her with the care and assistance she needed, and this contributed more than minimally, trivially or carelessly to Robin’s death.”
Testifying, CAMHS senior practitioner Carly Mandy admitted: “It was inappropriate to fire her.”
CAMHS clinical specialist Velani Bhebhe acknowledged that their assessment of Robin’s risk “was not detailed enough”.
The Sussex NHS Trust has begun implementing major changes to its mental health services, and Ms. Schofield will reconvene the investigation in three months to evaluate them.
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