A 12-year-old girl took her own life after being sectioned but medical staff did not detect her underlying brain disorder, an investigation has found.
On January 29 last year, Mia Lucas was found unconscious in her room at the Becton Centre, which is part of Sheffield Children’s Hospital.
Jurors heard Mia had undiagnosed autoimmune encephalitis – a rare condition that causes inflammation in the brain and which explains her “acute psychosis”.
The diagnosis was only revealed at the inquest in Sheffield, when a pathologist said he had just received new port-mortem examination test results.
On Thursday, the inquest jury concluded that a failure to perform a lumbar puncture at the Queen’s Medical Center (QMC) in Nottingham before his transfer to the Becton Center “probably contributed” to his death.
The inquest was told Mia began exhibiting unusual behavior over Christmas 2023, including hearing voices and attacking her mother. His family became so worried that he was taken by ambulance to QMC on New Year’s Eve.
He was found to be experiencing “acute mental disorder” and was charged under the Mental Health Act.
The jury of five women and four men heard that blood tests and MRI scans carried out at QMC were negative, leading doctors to rule out a physical cause for her psychosis.
However, physicians decided not to request further tests of brain activity or spinal fluid, including a lumbar puncture, which could detect autoimmune encephalitis.
Mia was transferred to the Becton Center on January 9 and died three weeks later.
In its descriptive conclusion, the jury said: “The failure to perform a lumbar puncture at this point (at QMC) meant that potential indicators of autoimmune encephalitis were missed. This probably contributed to Mia’s death.”
He said the information passed between QMC and the Becton Center “provides an inappropriate level of assurance that biological causes have been ruled out”.
In relation to the Becton Centre, the jury found that “inadequately strong communication and risk management led to a failure to respond adequately to Mia’s risk of self-harm”.
The jury also said that the “rare presentation of a rare condition” posed particularly complex challenges for diagnosis and care.
Jurors, instructed by Tanika Roden, Senior Coroner for South Yorkshire (West), found that Mia’s cause of death was neck compression due to acute psychosis caused by autoimmune encephalitis.
In a statement after the inquest, Mia’s mother, Chloe Hayes, said: “It is devastating to hear how, when she needed specialist health care for the first time in her life, she was so badly let down.
“He was released to the Queen’s Medical Center in Nottingham, which incorrectly decided that there was no underlying physical cause for his psychosis, and failed to carry out appropriate tests.
“I believe they simply dismissed him and wanted to transfer him to mental health services as quickly as possible, which led to him being transferred to the Becton Center.”
Mrs Hayes added: “Her mental health spiraled out of control there, as she was not being treated for her condition, and a number of failings and lack of care sadly meant she was not properly protected from harming herself.”
She said: “My beautiful little girl’s life has been lost and I will never forgive Queen’s Medical Center or the Becton Center for their failure.”
Dr Manjit Shehmer, medical director of Nottingham University Hospitals NHS Trust, said: “We accept the coroner’s findings in court today and apologize to Mia’s family for not having diagnosed autoimmune encephalitis when she was in our care.
“Although this is an incredibly rare condition and initial tests were negative, we recognize that further testing may have an impact on his future, for which we are truly sorry.”
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