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Neglect contributed to death of teenage boy.

Neglect by one of England's largest mental health trusts contributed to the death of a teenage boy, a coroner has ruled.

Chris Brennan, 15, died at Bethlem Royal Hospital, south London, in August 2014, six weeks after he was admitted for self-harming.

The coroner found a lack of a risk assessment and an up-to-date care plan had contributed to his death.

Coroner, Selina Lynch, said that the number of self-harming incidents on the unit had "de-sensitised" staff to the dangers.

Chris Brennan, who had mental health problems, repeatedly harmed himself while he was at the adolescent unit, run by South London and Maudsley NHS Trust.

South London Coroner's Court found there was no discussion about the number, or severity, of the incidents in a care meeting that took place days before the  teenager died from asphyxiation.

The court heard the unit was struggling to cope with basic functions, due to staffing issues, which led to poor morale and performance.

After the verdict, Chris Brennan’s family said: "Losing our beloved son and brother as a result of the hospital's failure to protect his life is unbearable. No other child should be allowed to die in this way."

In a statement the trust said: "Areas of learning for the trust were identified through a serious incident investigation and we have carefully reviewed our procedures accordingly.

"More recently, the service has been inspected by the Care Quality Commission and care was found to be of a 'good' standard. We hope this offers some reassurance to the family that lessons have been learnt from this very tragic event."

Chris Brennan was one of 11 young people to have died in psychiatric units in England between 2010 and 2014, according to the charity INQUEST which provides advice to people bereaved by a death in custody.

Outside court, the family's solicitor, Tony Murphy, said: "The family supports calls for health secretary, Jeremy Hunt, to commission an independent review into the deaths of children in psychiatric hospitals."

He added that deaths in psychiatric hospitals are not investigated by an independent body before inquests. This meant that coroners had to rely on evidence gathered by the very organisation that was being investigated.

Deborah Coles, director of the charity Inquest, which represented the family, said: “The lack of resourcing of child and adolescent mental health services across the country is a national scandal."






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