The mother of a 12-year-old girl who took her own life after she was sectioned has said she will never forgive the doctors who failed to spot she had an underlying brain disorder.
Chloe Hayes criticised a âfailure to provide appropriate care to her in her time of needâ after an inquest jury found inadequate testing at the Queenâs Medical Centre (QMC), in Nottingham, âpossibly contributedâ to the death of her âbeautiful little girlâ, Mia Lucas.
The trust which runs QMC later apologised to Mrs Hayes and her family, saying they were âtruly sorryâ that further tests were not carried out.
Mia was found unresponsive in her room at the Becton Centre, which is part of Sheffield Childrenâs Hospital, on January 29 2024.
The jurors heard how Mia was suffering from undiagnosed autoimmune encephalitis, which is a swelling of the brain, which would have been the cause of the acute psychosis she was exhibiting.
This diagnosis only emerged part-way through the nine-day long inquest, after a pathologist revealed she had just received new post-mortem examination test results, provoking shock in the courtroom and tears among Miaâs relatives gathered in the public gallery.
On Thursday, the jury found that the failure to undertake a lumbar puncture at QMC before her transfer to the Becton Centre âpossibly contributed to Miaâs deathâ.
The jury also said there was a failure at the Becton Centre to respond adequately to Miaâs risk of self-harm.
In a statement after the inquest, Mrs Hayes said: âIt has been devastating to listen to how, when she needed specialist healthcare, for the first time in her life, she was so badly let down.
âShe was let down at the Queenâs Medical Centre in Nottingham, who wrongly decided there was no underlying physical cause of her psychosis, and failed to carry out appropriate testing.
âI believe they simply dismissed her and looked to pass her onto mental health services as quickly as possible, which led to her transfer to the Becton centre.â
Mrs Hayes continued: âHer mental health spiralled deeper out of control there, as she was not being treated for her condition, and the many failings and lack of care meant sadly she wasnât properly protected from harming herself.â
She said: âMy beautiful little girl has lost her life and I will never forgive the Queenâs Medical Centre or the Becton Centre for failing her.â
Mrs Hayes said the Becton Centre âproved to be completely unsuitable for her, and one which failed to keep her safeâ.
She said: âI have never believed for a moment that Mia ever wanted to take her own life. She was always a happy, healthy child and had so much to live for.â
Mrs Hayes said she wanted everyone to know that Miaâs extreme behaviour was only evident in the final few weeks of her life and âfor the other 12 years, she was a beautiful soul who loved life and loved her family, and thatâs how we want her to be rememberedâ.
She said she was âhappy, fun, friendly girl who had so much to live for.â
The inquest heard how Mia began to began to behave strangely over Christmas 2023 â including hearing voices and attacking her mother â and her family became so concerned she was taken by ambulance to QMC on New Yearâs Eve.
She was found to be experiencing an âacute psychotic episodeâ and was also sectioned under the Mental Health Act.
The jury of five women and four men heard how blood tests and an MRI scan were untaken at QMC which were found to be negative and doctors ruled out a physical cause of Miaâs psychosis.
But doctors at Nottingham decided not to order further tests on brain wave function and spinal fluid, through a lumbar puncture, which may have revealed the autoimmune encephalitis, which is very rare.
Mia was transferred to the Becton Centre on January 9 and died three weeks later.
In a narrative conclusion, the jury said: âThe failure to undertake a lumbar puncture at this point (at QMC) meant that potential indicators of autoimmune encephalitis were missed.
âThis possibly contributed to Miaâs death.â
The jury added that the information passed between QMC and the Becton Centre âprovided an inappropriate level of assurance that organic causes had been ruled outâ.
In relation to the Becton Centre, the jury concluded that: âInsufficiently robust communication and management of risk led to a failure to respond adequately to Miaâs risk of self-harm.â
The jury also said that a ârare presentation of a rare conditionâ provided âparticularly complex challengesâ for diagnosis and care.
The jurors found, on the directions of the senior Sheffield coroner Tanyka Rawden, that Miaâs cause of death was âcompression of the neckâ, caused by âacute psychosisâ, caused by âautoimmune encephalitisâ.
They heard how Mia self-harmed in her three weeks at the Becton Centre, but the coroner said there was not enough evidence for the jury to find staff handovers on January 29 contributed to Miaâs death.
Mrs Rawden said she will be writing to Health Secretary Wes Streeting, along with a number of professional bodies, about her concerns about the lack of national guidance over testing for autoimmune encephalitis.
She said she was satisfied she did not need to write to Sheffield Childrenâs Hospital after hearing about a range of changes at the Becton Centre.
And Mrs Rawden said she would wait six months, to let Nottingham University Hospitals finish its own investigation, before considering a letter to that trust.
Ms Hayesâs solicitor Amy Rossall, of Hudgell Solicitors, said: âWeâve heard many comments about lessons being learned as a result of what happened to Mia, and those learnings will hopefully help to avoid other families losing their children to the condition.â
Dr Manjeet Shehmar, medical director at Nottingham University Hospitals NHS Trust (NUH), said: âWe accept the coronerâs outcome in court today and apologise to Miaâs family for not identifying autoimmune encephalitis while she was in our care.
âWhile this is an incredibly rare condition and initial tests were negative, we recognise that further testing may have had an impact on her future, for which we are truly sorry.â
Dr Jeff Perring, executive medical director at Sheffield Childrenâs NHS Foundation Trust, said: âWe are deeply sorry for Miaâs death and recognise the profound impact this has had on those who loved her.â
Dr Perring outlined the changes made at the Becton Centre following a review of Miaâs care and said a CQC inspection in September found it to be âsafe and staff there caring and responsive to patient needsâ.
