29 May 2024

This is a media release by Ison Harrison, reshared by INQUEST

Before HM Assistant Coroner Elizabeth Wheeler
Northampton Coroner’s Court
Heard 13 – 17 May 2024

Grace Smith, aged 16, died on 5th August 2022 at Rainbows Hospice for Children and Young People in Loughborough after a self-inflicted ligature at St Andrew’s Healthcare in Northampton.

An inquest jury has found that Grace died as a result of suicide, contributed to by a failure to adequately consider her risks and triggers given known and available information. The jury considered this led to a missed opportunity to render care.  

Born in Milton Keynes, Grace was a thoughtful, caring, kind and loving daughter. She was always thinking about others.

Factual Background 

Grace had a complex history of mental health problems including bipolar disorder, eating disorder, severe self-harm, suicide attempts and post-traumatic stress disorder. 

In December 2021, Grace was under the care of Beacon Ward, a CAMHS general adolescent inpatient unit. Due to her considerable risk of self-harm, she had been on constant 1:1 observations, which were subsequently reduced to observations every 5 and then every 10 minutes.

On the day that her observations were reduced to 10 minutes, Grace made a significant attempt on her life, which required hospital treatment before being returned to the unit.  Her observations were increased back to constant 1:1.

She later explained to her psychologist that she had planned to make an attempt on her life and had been waiting for staff to reduce her observations to 10 minutes in order to do so. She had a known history of masking her suicide risks.

Grace continued to self-harm and on 18th January 2022 she was transferred to St Andrew’s Hospital, a low secure unit in Northampton, as she could not be managed safely on Beacon Ward. 

On 19th January 2022, Grace’s community home Almond Care served notice on her placement. Grace was informed of this on the following day. All staff involved agreed that Grace’s risk of suicide would increase significantly following receiving this news, as she was likely to feel hopeless and ‘stuck’ in hospital. St Andrews’s staff placed Grace on constant 1:1 observations as a result. 

Grace’s community psychologist, who had worked with her for a number of years, said during the inquest that she considered Grace’s risk following receiving this news would have remained high until the issue of community placement was resolved. 

Grace had continued incidents of self-harm and made further attempts on her life after this news. In the days before her death, Grace was self-harm free but there were incidents of aggression towards staff at the hospital and Grace was noted to be experiencing paranoia and hallucinations. These were recognised risk factors, by both her community team and the staff at St Andrews on admission, for Grace’s mental health being in decline. 

On 10th February 2022, a Care Plan Update Meeting was held involving staff at St Andrew’s Hospital and two community professionals. Following this meeting, Grace’s observations were reduced from constant 1:1 observations to 15-minute observations for a trial period of 1 hour per day. The trial period was to take place between 12:00 and 13:00.

Staff at St Andrews gave evidence they did not consider any additional measures were necessary alongside the reduction. There was no direct discussion noted in any of the minutes produced of the meeting of the incidents of aggression, paranoia or hallucinations.

The inquest also heard evidence that not all those that attended that Care Plan Update Meeting were aware that the reduction in Grace’s observations had been agreed. Grace’s social worker from Lincolnshire County Council said that she did not believe they had made the decision to reduce the observations during that meeting. Had she been aware, she would have wanted to test the decision was safe and (although she would have taken the lead from Grace’s community psychologist) would have spoken up or contacted staff about the decision.

At 12:00 the following day, on 11th February 2022, Grace’s observations were reduced. During this period, she sat in an empty room on her own, with the door closed. She sat in the corner of the room out of view of the CCTV. 

Staff recorded that they carried out checks more frequently than every 15 minutes due to concerns about Grace’s risk. However, CCTV shown during the inquest showed the 12:35 check in particular lasted approximately six seconds. Grace’s family continue to raise concerns that these checks were extremely brief and about the quality of those checks. 

At 12:47, staff found Grace had ligatured and was non-responsive. A medical emergency was declared, and Grace was taken to hospital by paramedics. 

On 14th February 2022, scans identified that Grace had suffered a hypoxic brain injury with poor prognosis for recovery. Grace was later transferred to Lincoln General Hospital and, on 22nd July 2022, to Rainbow’s Hospice for end-of-life care. Grace died on 5th August 2022. 

Inquest Findings

Evidence around Grace’s care at St Andrews, and the decision to change her observations in particular, was heard before a jury over the course of 5 days at Northampton Coroners Court. The jury found that at the time of the decision to reduce her observations there was a failure to adequately consider Grace’s risks and triggers given the known and available information and that this led to missed opportunity to render care. 

The jury concluded that Grace died as a result of suicide, contributed to by a failure to adequately consider her risks and triggers given known and available information. 

Rachel Smith, Grace’s mother, said: "Grace had so much planned for her future. She was bright, funny, caring and so much more but because of what happened at St Andrew’s her future was taken away from her.

The failings at St Andrew’s that the jury found to have contributed to my daughter’s death, I believe could have been prevented. My heart aches every day, knowing she’d still be here if they did things right. 

My amazing Grace will never be forgotten and will always be loved forever.

Grace leaves behind her twin sister, Reanne, who is utterly heartbroken by Grace’s death."

Megan Spurr, at Ison Harrison Solicitors, said: "This is an extremely sad case involving a vulnerable young woman. 

Grace had self-harmed on a considerable number of occasions prior to her admission at St Andrew’s Hospital and was clearly a high-risk patient who had a history of waiting for her observations to be reduced before using the opportunity to make an attempt on her life.

Despite the high-risk behaviour that she demonstrated before the decision to reduce the observations, and her known history of using reductions in observations to ligature, the decision was made to trial reducing those observations to only four checks per hour for an hour a day. 

Sadly, Grace’s death is one of many at mental health inpatient units across the country."


Journalists should refer to the Samaritans Media Guidelines for reporting suicide and self-harm and guidance for reporting on inquests.