Medical neglect and “gross failures” by a mental health trust contributed to the suicide of a 12-year-old girl in a case that has highlighted national concerns about underfunding, a coroner has ruled.
Allison Aules from Redbridge in north-east London died in July last year after her mood changed completely during the Covid lockdown, her family told the inquest at an east London coroner’s court.
At the conclusion of the inquest, the area coroner Nadia Persaud highlighted a series of failures by North East London NHS foundation trust (NELFT) that contributed to her death. In a narrative verdict she ruled it was a “suicide contributed to by neglect”.
Persaud also said failures in Allison’s care raised wider national issues about under-resourcing and “outstanding concerns” about the lack of consultant psychiatrists.
These will be addressed later in a prevention of future deaths report. Persaud told the court: “There are national concerns around children and adolescent mental health services … and I’m also going to write a report at the national level to reduce the risk of this happening again.”
Persaud said Allison’s case showed “both operational failures of individual practitioners and systemic failings on behalf of the trust”.
She added: “This was on a backdrop of a very under-resourced service.”
In her verdict Persaud said: “Allison didn’t receive the mental health care which she should have received and I find that the absence of care contributed to her death.”
Echoing the words of an expert who assessed Allison’s treatment, Persaud said: “I’m satisfied that there was a causal connection between the gross failure identified and Allison’s death.”
The inquest heard that Allison was referred to the service for help in May 2021, by her school, over concerns about evidence of self-harm, low mood, anxiety and bed-wetting.
Persaud said Allison’s case was initially “inappropriately” screened as routine and that an “essential” face-to-face assessment was never conducted. Persaud said: “Alice’s voice was never heard. She had no opportunity to discuss and explain her difficulties in an agreed safe space.”
Persaud detailed a series of blunders by the trust’s child and adolescent mental health service team. She said it failed to conduct a risk assessment before Allison was discharged in April last year, less than four months before her death. And there was no team discussion about this decision or any involvement of a qualified psychiatrist, the court heard.
Persaud added: “The school counselling that was relied upon on discharge had only started the week before. Allison was refusing to attend school on some days and there was a clear written chronology of deterioration in her mental state from July 2021 to April 2022.”
Persaud noted that the school counselling ended on 15 July last year, four days before her death.
Wellington Makala, the executive director of psychological professions at NELFT, apologised to the family. Addressing them directly from the witness box, he said: “There is nothing we can say to bring your daughter and your sister back. Mistakes were made in the care of Allison. For that we are sorry. We will do everything we can to ensure there is learning from this death. On behalf of the organisation, I am sorry for your loss.”
Speaking through an interpreter, Allison’s mother, Margarita, said: “Whatever happened to Allison I don’t know how to describe this experience, but I thank God I haven’t lost my sanity from the pain. This gives me strength to move forward with my other children. I hope they [NELFT] will put in place all the things they say they will do, so other families don’t have to suffer.”