9th May 2016

10am, Before HMC Penelope Schofield

Horsham Coroners Court, County Hall North, Horsham

Time estimate: 2 - 3 weeks

14 year old Amy El-Keria had complex needs associated with multiple mental health diagnoses.  Following referral by West London Mental Health Trust, she was admitted on the 24 August 2012 as a patient to Ticehurst House.  Ticehurst House is a private psychiatric hospital run by the Priory Group in Wadhurst, East Sussex, with a separate 18 bed specialist Child and Mental Health (CAMHS) High Dependency Unit.  This was Amy’s first admission to a psychiatric hospital. 

According to the Priory, at about 8.17pm on 12 November 2012 a healthcare assistant found Amy’s bedroom locked.  She returned with keys to access Amy’s room and found her collapsed on the floor with a ligature around her neck.  An ambulance was called and she was transferred to Conquest Hospital, Hastings where she never recovered.  The family were  informed of events at approximately 11pm.    

Amy was designated to be on a 15 minute observation regime throughout her admission. 

The Interested Persons in the inquest proceedings are Amy’s family, the Priory, two individual doctors, West London Mental Health NHS Trust and London Borough of Hounslow Social Services.

Amy’s family hope the inquest will address key questions surrounding her admission to the Priory, including the:

  • Decision to place Amy so far away from home;
    • Assessment of Amy’s risk of self-harm;
    • Communication between staff;
    • Contact from the Priory to Amy’s family; 
    • Use of restraint and forced medication;
    • Management and safety of the environment, including of Amy’s room;
    • Effective administration of Emergency Life Support; and
    • Compliance with key policies and record keeping, including ligature audits and observations.

Amy’s mother, Tania El-Keria, said:

“West London Mental Health NHS Trust funded this referral to the Priory for Amy to secure the help we as a family knew she so desperately needed.  We want to know how our Amy came to die while under the care of this specialist unit and we truly hope this inquest will give us answers.  Nearly four years since her death, it has been a long and painful wait.” 

Deborah Coles, INQUEST, said:

“This is the first time since her death in 2012 that the facts and circumstances of Amy’s death will be independently examined.  At a time when so many concerns are being raised about the state of mental health services for children and young people, this is a critically important inquest.”

INQUEST has been working with the family of Amy El-Keria since shortly after her death.  The family is represented by INQUEST Lawyers Group members Tony Murphy of Bhatt Murphy solicitors and barrister Raj Desai of Matrix Chambers.




Notes to editors:
• Amy El-Keria is one of at least 11 child deaths of mental health in-patients INQUEST has identified over the period 2010 to 2014 through its casework and through the conduct of an extensive FOI exercise: http://www.inquest.org.uk/media/pr/number-of-hild-in-patient-mental-health-deaths-not-known. 
• Through its research, INQUEST has established that no single body is responsible for recording the deaths of children who die as mental health in-patients. This crucial information is neither collated nor analysed or made public by any one body or government department.
• INQUEST met with Alistair Burt, Minister for Health, on 21 April 2016, to discuss some of the issues raised through INQUEST’s research.
• Approximately 47% of all in-patient child and adolescent mental health services are now provided by private providers, including the Priory.  
• There is currently no pre- inquest system of independent investigation into the deaths of children who die as mental health in-patients.  In Amy El-Keria’s case, the ‘Serious Incident Investigation’ (not yet published) reviewing the care and treatment received and the circumstances surrounding her death was conducted by a CAMHS Specialist Consultant based at the Priory Hospital North London. 

Source: INQUEST Casework and monitoring