A series of failures by a mental health trust contributed to a 12-year-old girl taking her own life, a leading child psychiatrist has told an inquest.
Allison Aules from Redbridge in north-east London died in July last year after her mood changed completely during the pandemic, her family say.
North East London NHS foundation trust failed to act on several warning signs about her wellbeing, including a history of self-harm, bed-wetting and school refusal, an inquest at east London coroner’s court was told on Wednesday.
Duncan Harding, a consultant forensic psychiatrist in children and adolescents and a mental health clinical lead in south London, said there was overwhelming evidence that the trust’s decision to discharge Allison in April 2022 without meeting her in person and without discussion with a psychiatric team contributed to her death.
Harding said closing the case was wrong and would have “shut off hope” for Allison. He also expressed alarm that the decision to discharge her was made “autonomously” by a management team set up to clear a backlog in cases that had built up during the pandemic.
Harding was asked to review the NHS trust’s handling of the case by the area coroner Nadia Persaud. The coroner said she shared Harding’s “surprise” that Allison was discharged without being assessed face to face and without the involvement of a psychiatrist.
“Allison’s voice appears to be lost in this,” Harding told the court.
Allison was referred to the trust’s child and adolescent mental health service (Camhs) by her school in May 2021 after a PE teacher recognised her self-harming scars. In a letter to the service the school’s deputy head wrote that Allison’s bedwetting and self-harm raised “red flags”. The teacher wrote: “We believe this young lady is in need of support for her worrying behaviour.”
Harding said: “The school’s use of the phrase ‘red flag’ is of great significance in clinical services.”
Other warning signs included Allison’s exposure to pornography and the discovery of dark poems and stories she had written, Harding told the court. He said there were a number of “missed opportunities” to help Allison, including initially assessing her case as routine.
This meant she was not contacted by a mental health nurse for another 11 months and then only by phone with her mother present, the inquest heard. Harding said: “The missing piece is what was her mental state: was she being bullied or abused online? We don’t know … She should have been seen face to face … and she needed to be seen more urgently.”
Patience Chabvuta, a mental health nurse and therapist who was brought into lead the trust’s emotional wellbeing service a month after Allison’s death, told the court the decision to discharge her was safe but conceded it was “not robust”.
She said Allison was discharged because she was showing signs of improvement since starting to see a school counsellor.
But Harding said that by the time Allison was discharged there was “a clear documented” worsening of her mental health as she was refusing to go to school on certain days. “It is clear that there is a deterioration in her mental state that can’t be managed by the school, because she is refusing to go to school. Closing the case doesn’t make any sense to me.”
He added: “Even if nothing had been done, having the case open with Camhs gave her hope, closing the case shut off hope.”
Speaking through an interpreter, Allison’s mother, Margherita, who is from Ecuador, told the court: “I’m surprised you [a mental health nurse] took the decision to discharge her without seeing her face to face. Why was there was no discussion with the school counsellor?”
The inquest continues.
In the UK and Ireland, Samaritans can be contacted on freephone 116 123, or email [email protected] or [email protected]. In the US, you can call or text the National Suicide Prevention Lifeline on 988, chat on 988lifeline.org, or text HOME to 741741 to connect with a crisis counselor. In Australia, the crisis support service Lifeline is 13 11 14. Other international helplines can be found at befrienders.org