The lack of resources for children’s mental health services in the UK has been described as a “national scandal” after a coroner ruled that neglect and “continuing failures” at one of the largest mental health trusts in England contributed to the death of a teenage boy.
Christopher Brennan, 15, died after being found unconscious at Bethlem Royal hospital in south London in August 2014. He had been admitted to the psychiatric hospital’s adolescent unit six weeks earlier as his family and local mental health services felt unable to keep him safe at home.
Christopher had a history of harming himself, and a deterioration in his mental health over the two years before his death led to repeated hospital admissions.
The coroner found that no formal risk assessment was carried out during his stay at Bethlem hospital, which is run by South London and Maudsley NHS foundation trust, and there was no care plan in place, according to the charity Inquest, which is supporting his family.
South London coroner’s court heard he was also allowed access to a number of items in hospital which he used to self-harm.
On 31 August 2014 Christopher was found unconscious in a communal toilet and later died after suffering a cardiac arrest.
Handing down her ruling on Wednesday, the coroner, Selena Lynch, said: “Christopher’s actions were in part because of cumulative and continuing failures in risk assessment and management. His death was contributed to by neglect.”
The hospital trust offered its “sincere apologies” to his family and said it had reviewed its practices. A spokesman 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.”
Following the inquest Christopher’s family said: “Losing our beloved son and brother when he was just 15 years old was so painful. Losing him as a result of the hospital’s failure to protect his life is unbearable.
“Chris will never be forgotten and no other child should be allowed to die in this way.”
Christopher was one of at least 11 young people to die in psychiatric units in England between 2010 and 2014, according to Inquest.
Deborah Coles, the charity’s director, said: “Sadly, Chris’s death is not an isolated one. Incredibly, we find that no single body is responsible for collating, analysing or publicising these deaths and that these deaths are not being independently investigated.
“The lack of resourcing of child and adolescent mental health services across the country is a national scandal. The only possible response to this case and the growing public outcry and disquiet around mental health services for children and young people is for an urgent independent review. We call upon the government to now take this necessary step.”
Neglect contributed to teenager"s death in psychiatric hospital, coroner rules
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