Girl, 12, killed herself after medical staff failed to spot brain disorder, inquest finds | UK news
A 12-year-old girl who committed suicide after being sectioned was failed by medical staff who failed to recognize her underlying brain disorder, an investigation has found.
Mia Lucas was found unresponsive in her room at the Becton Centre, part of Sheffield children’s hospital, on January 29 last year.
Jurors heard Mia suffered from undiagnosed autoimmune encephalitis, a rare condition that causes swelling of the brain and explains her “acute psychosis”.
The diagnosis emerged halfway through the inquest in Sheffield after a pathologist said he had received new post-mortem examination results.
The inquest jury on Thursday concluded that failure to carry out a lumbar puncture at Nottingham Queen’s medical center (QMC) before he was transferred to the Becton Center “probably contributed” to his death.
The inquest was told Mia began exhibiting unusual behavior around Christmas 2023, including hearing voices and attacking her mother. His family was so worried that he was taken to QMC by ambulance on New Year’s Eve.
He was found to be suffering from an “acute psychotic episode” and was subject to investigation under the Mental Health Act.
A jury of five women and four men heard that blood tests and an MRI scan at QMC were negative, leading doctors to rule out a physical cause for his psychosis.
But clinicians decided not to order any further tests of brain activity or spinal fluid, including a lumbar puncture that might have revealed autoimmune encephalitis.
Mia was transferred to the Becton Center on January 9 and died three weeks later.
The jury said in its final declaration: “At this point, lumbar puncture should not be performed.” [at QMC] It meant that potential indicators of autoimmune encephalitis were missed. This likely contributed to Mia’s death.
They added that the information passed between QMC and the Becton Center “provided an inappropriate level of assurance that organic causes had been excluded.”
The jury found that “insufficiently robust communication and risk management” in relation to the Becton Center resulted in Mia’s failure to adequately respond to the risk of self-harm.
The jury also noted that “the rarity of a rare condition” creates particularly complex challenges for diagnosis and care.
Jurors, on the instructions of South Yorkshire (West) senior coroner Tanyka Rawden, found that Mia’s cause of death was neck compression resulting from acute psychosis caused by autoimmune encephalitis.
Mia’s mother, Chloe Hayes, said in a statement following the inquest: “It was devastating to hear how she was so disappointed when she needed specialist healthcare for the first time in her life.
“He was disappointed that the Queen’s medical center in Nottingham incorrectly concluded that there was no underlying physical cause for his psychosis and failed to carry out appropriate tests.
“I think they terminated him and tried to transfer him to mental health services as quickly as possible, which led to him being transferred to the Becton Center.”
Ms Hayes continued: “His mental health spiraled further out of control there as he was left untreated for his condition and the many failures and lack of care meant he was unfortunately not properly protected from self-harm.”
He said: “My beautiful little girl has lost her life and I will never forgive the Queen’s medical center or the Becton Center for failing her.”
Nottingham University Hospitals NHS Trust medical director Dr. Manjeet Shehmar said: “We accept the coroner’s conclusion in court today and apologize to Mia’s family for not being able to detect autoimmune encephalitis while she was in our care.
“Although this is an incredibly rare condition and initial tests have been negative, we recognize that further testing could impact his future and for this we are truly sorry.”
