Jury finds shortcomings, flaws and failures in care of detained child: Karen Boyle acts in Article 2 Inquest
Karen Boyle represented the maternal family of Mia Maisie Lucas in an Article 2 inquest at Sheffield Coroner’s Court presided over by the Senior Coroner for Sheffield, Ms Tanyka Rawden, sitting with a jury.
Mia, who was a treasured and much-loved daughter, was admitted to QMC Hospital in Nottingham on 31 December 2023 following increased concerns for her welfare by her family. She had been displaying unusual behaviours and struggling with her mental health in the preceding 2.5 months which were heightened after a viral infection in December 2023. Organic causes of her behaviour were allegedly ruled out, and Mia was transferred to the Becton Centre at Sheffield Children’s Hospital on 9 January 2024 for further care and investigation of her psychosis. Mia was found unresponsive in her bedroom at the Becton Centre on 29 January 2024 whilst she was detained under the Mental Health Act.
During a nine-day inquest eighteen live witnesses gave evidence, during which evidence from an independent Paediatric Neurologist was heard. Professor Marta Cohen, Pathologist, gave evidence changing, and updating her opinion, as to the medical cause of death, during the inquest. New tests results proving NMDA receptors and killer T cells were positive within samples taken from Mia post-mortem.
The jury delivered a narrative conclusion finding that there were failings in the care of Mia. The jury found that the failure to undertake a lumbar puncture meant that potential indicators of autoimmune encephalitis were missed and this possibly contributed to Mia’s death. In addition, the information given to the Becton Centre lacked sufficient detail concerning the completeness of physical tests, providing an inappropriate level of assurance that organic causes had been ruled out.
Whilst at the Becton Centre the jury found that there were four ligature incidents and insufficiently robust communication and management of risk led to a failure to respond adequately to Mia’s risk of self-harm. The jury found a more robust approach to communication and risk could have led to greater awareness and more checks being undertaken.
HM Senior Coroner indicated her intention to write a Prevention of Future Death report addressed to the Secretary of State for Health, the Royal College of Paediatricians and Royal College of Psychiatrists in respect of the lack of national guidelines for the diagnosis and management of those with suspected auto immune encephalitis, concerning the risk of future deaths.
Further information can be found using the following links: BBC News – Sky News – Hudgells Solicitors News
Ms Boyle was instructed by Amy Rossall of Hudgell Solicitors.
