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Multiple agency failures contributed to teen's death, coroner rules


A teenager who died after an attempt to end their life in hospital while waiting for a mental health bed was repeatedly failed, a coroner concluded.

Madeleine Savory, 15, died at Ipswich Hospital, Suffolk, in February 2022 and the coroner said failures at Ipswich Hospital, Northgate High School and concerning the unavailability of mental health beds, contributed to her death.

Madeleine had self-harmed on 3 February 2022 after leaving Northgate High School, Ipswich, but the school did not raise an alarm about her absence for more than an hour, the inquest heard.

She was admitted to hospital and placed on a list for a mental heath unit bed on 7 February but, while waiting for this, made an attempt on her life on 19 February and died a week later.

Madeleine, who had a history of self-harm, had been first referred to Norfolk and Suffolk NHS Foundation Trust (NSFT), which cares for people with mental health difficulties, after a hospital admission in September 2021.

Suffolk coroner, Darren Stewart, said failures at Northgate High School, on Bergholt ward, and the acute paediatric ward at Ipswich Hospital, and concerning the unavailability of urgent tier-four mental health beds for children, all “more than minimally” contributed to Madeleine Savory’s death.

In his findings, Mr Stewart criticised the school for a failure to recognise the importance of Madeleine Savory being missing. He said they had "failed to effectively implement the safety plan for Madeleine specifically designed to keep Madeleine safe."       

East Suffolk and North Essex NHS Foundation Trust (ESNEFT), which runs Ipswich Hospital, also failed Madeleine in multiple ways.

Mr Stewart said staff had a "naivety" when it came to children with mental health conditions, adding there was a "failure to implement the relevant policies” which led to "staff on Bergholt ward not having the necessary understanding of Madeleine's risk" or how to manage it.

He also found failings in the "ad-hoc" basis on which risk assessments had been conducted, with just three being done during two days but he added that the unavailability of tier-four beds nationally was "at the heart of the inquest.”

Madeleine had been on a waiting list for a bed for 12 days when she made an attempt on her life. The court was told there was a national shortage, with average wait times in the East of England of 46 days.

In a statement, Madeleine Savory’s family said they were "heartbroken and devastated." They said it was "particularly distressing" to hear of Madeleine being treated on a ward with an "amateurish and incompetent approach to mental health, safeguarding and risk.”

They added that Madeleine's death was "entirely foreseeable and preventable", adding: "We hope that lessons will be learnt to avoid another child and family having to go through the indescribable pain and torment we have endured."

Mr Stewart said he would hold a further hearing to discuss "a number of concerns", including the failures raised at the inquest, for inclusion in a Prevention of Future Deaths Report.

Chief medical officer at East Suffolk and North Essex Foundation Trust (ESNEFT), Dr Angela Tillett, said that since Madeleine's death "significant changes" had been made into the care of young people.            

Deputy chief executive at NSFT, Cath Byford, said: "We are committed to working with our health partners to learn from Madeleine's tragic death."