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INQUEST INTO CHILD DEATH FINDS FAILINGS IN CARE CONTRIBUTED TO SUICIDE
2 May 2017
Before HM Assistant Coroner Andrew Bridgman
Manchester South Coroner’s Court
18 April – 2 May 2017
The inquest concerning the death of 15 year old Pippa “Pip” McManus has concluded. Pip suffered from Anorexia and was formally an inpatient at the Priory Hospital Altrincham at the time of her death on 9 December 2015. During the inquest the Priory said hers was one of the most severe cases of Anorexia they had seen. The jury found that her death was a suicide, with the following contributory factors:
• Inadequate community care and specialist post-discharge support for Pip and her family.
• Failure to implement a timely care plan and lack of cohesiveness amongst agencies.
• Inadequate communication of enhanced risk of suicide on discharge.
Pip suffered from Anorexia since she was 12 and was detained under section 3 of the Mental Health Act at The Priory Hospital Altrincham on 9 September 2014. Her placement was funded by NHS England. Pip remained at the Priory’s Rivendell Unit as a formally detained in-patient until her death. She had been granted home leave ahead of completion of the formal discharge process from the Priory Hospital. Five days into her leave she left her home, walked to the nearby train station and died when struck by a train.
The jury heard evidence that inadequate steps were taken to plan for and ensure the implementation of necessary care and support arrangements to support Pip’s discharge. The first days after discharge are the most significantly risky time for patients. However, this high risk was never communicated to Pip’s parents who felt they had no option but to 'go along' with the discharge. Pip had a history of acting impulsively in response to boundaries, including running out of the house and becoming very distressed and her family had repeatedly expressed concerns as to how they would manage.
As of 4 December (the start of Pip’s leave leading to discharge) no social support worker had met Pip or her parents, and Trafford Child and Adolescent Mental Health Services (CAMHS) failed to put any clear care plan in place. Providing independent expert evidence to the inquest, Dr Paul Millard criticised the Trafford CAMHS consultant psychiatrist for failing to hold meetings with either Pip or her parents. There was also little evidence of attempts by the Priory family therapist to engage with the family in the period before or after discharge. This is despite significant focus on family therapy as being crucial for parents and families to gain the tools and understanding to manage Anorexia at home.
HMP Coroner Andrew Bridgman will be issuing a Prevention of Future Deaths report, including community care planning.
Marie and Jim McManus, Pip’s parents said:
“Our beautiful daughter, Pip took her own life on 9 December 2015. She was just 15 years old. The tear in the thread of our family will never be mended. Pip spent her last three years fighting against anorexia, malnutrition, depression and self harm. We believe the failings in our daughter’s care from beginning to end resulted in her death.
Anorexia has the highest mortality rate attributed to any psychiatric illness (with as many as 40 deaths due to suicide). Too many of our children are dying from this terrible illness. Effective treatment is needed more quickly and if this had been available to our beautiful daughter maybe she would still be alive today. Maybe we would not have needed this inquest.
We do not want Pip’s life and suffering to have been in vain. Whenever she was able she tried to help others with similar conditions. We are planning to continue her good work through the Pip Foundation, in aid of The Anorexia and Bulimia Care Charity. We especially want to create a dedicated early intervention centre to help young people and their families called 'Pip’s Place'. Through this, Pip will never be forgotten, her memory will live on.”
Deborah Coles, Director of INQUEST said:
“Pip’s death has exposed a mental health system which pushed through the discharge of a highly vulnerable child without any of the support or care in place to make sure she would be safe. Her terrified family knew there was huge risk. Their concerns were dismissed and minimised throughout.
INQUEST holds serious and ongoing concerns over the continuing lack of scrutiny and oversight of young deaths in mental health care. The Government has a moral and legal duty to ensure the safety of our children. Ministers must meet now with affected families to inform the urgent and necessary reform of the current system, to prevent further tragic deaths.”
Komal Hussain, Minton Morrill solicitors said:
“This is an extremely tragic case involving a young and charismatic girl who fell victim to anorexia nervosa which brought with it a vicious cycle of difficulties that Pip and her family tried so hard to overcome on a daily basis. This case amplifies the ongoing need for improvements and changes that need to be made to inpatient and community mental health services nationally to protect the lives of vulnerable young people and their families, who rely upon the support of the system to safeguard them.”
INQUEST has been working with the family of Pippa McManus since her death. The family is represented by INQUEST Lawyers Group members Gemma Vine and Komal Hussain of Minton Morrill Solicitors and Kirsten Sjovoll of Matrix Chambers.
NOTES TO EDITORS
For further information, please contact: Lucy McKay on firstname.lastname@example.org or 020 7263 1111
1. For a full background on Pippa and her death see our inquest opening press release.
2. INQUEST has ongoing concerns about the lack of oversight and scrutiny over the deaths of children and young people in mental health care. There is no single body responsible for recording the deaths of children who die as mental health in-patients, meaning we simply do not know how many children have died in these settings or the circumstances of their deaths.
3. There is no pre-inquest system of independent investigation into the deaths of children who die as mental health in-patients, such as those done by the Prison or Probation Ombudsman or IPCC, something which INQUEST have repeatedly called for.
4. For more information on our concerns over children’s deaths in mental health settings see INQUEST’s report Deaths in Mental Health Detention: An investigation framework fit for purpose? here (focus on children in mental health settings from pg.20).
5. The Pip Foundation fundraising page by Pip's family can be found here.
INQUEST provides specialist advice on deaths in custody or detention or involving state failures in England and Wales. This includes a death in prison, in police custody or following police contact, in immigration detention or psychiatric care. INQUEST's policy and parliamentary work is informed by its casework and we work to ensure that the collective experiences of bereaved people underpin that work. Its overall aim is to secure an investigative process that treats bereaved families with dignity and respect; ensures accountability and disseminates the lessons learned from the investigation process in order to prevent further deaths.
Please refer to INQUEST the organisation in all capital letters in order to distinguish it from the legal hearing.