AN INQUEST into the death of an Almondsbury teenager has found that failings in mental health services “possibly contributed” to her death.
Castle School student Lucy Curtis, who was 17, died on New Year’s Day 2024, five days after a self-harm incident whilst an inpatient at Riverside Adolescent Unit at Blackberry Hill Hospital in Bristol.
The unit run, by the Avon and Wiltshire Mental Health Partnership NHS Trust (AWP), closed shortly after the incident and has not reopened.
The trust has apologised and Lucy’s care “fell short of the standards she and her family deserved”.
Lucy’s parents said they believe her death was “preventable and avoidable”, and she would still be alive had concerns about her care been acted upon sooner.
Delivering a narrative conclusion in July, a jury at Avon Coroner’s Court found delays in getting specialist mental health support also “possibly contributed” to Lucy’s death.
Lucy died at Southmead Hospital, a few days after being found unresponsive at the unit for patients aged between 13 and 18 with “complex and enduring mental health difficulties”.
The inquest found the unit’s failures included not adhering to 15-minute check-up intervals and delays in delivering life-saving medical support.
Seven-month wait for first appointment
The jury heard Lucy’s contact with mental health services started in January 2023, when she visited her GP with anxiety, low mood, and self-harm.
The doctor referred her to Child and Adolescent Mental Health Services (CAMHS) but the referral was declined the next day.
Lucy was referred back to CAMHS a second time in April 2023, after being seen at hospital following self-harm, but the referral was closed shortly afterwards.
A third referral was made in May that year, after which she was added to a waiting list.
It took until August, after an incident which revealed a risk she planned to end her life, before Lucy had an initial CAMHS appointment.
She had two more weekly sessions before an incident when she went missing from the family home overnight and was admitted to an inpatient mental health unit in Bridgwater, Somerset, as a voluntary patient.
The inquest heard that while Lucy was at that unit, run by Somerset NHS Foundation Trust, her self-harm escalated. Her parents were told by staff that they could not stop her from going out unsupervised, as she was a voluntary patient.
The jury also heard that it had been practice not to remove risky items used for self-harm if Lucy was not considered to be at immediate risk of serious harm.
This led to an incident in November 2023, where Lucy suffered a significant injury.
‘Hostile’ response
A meeting was held about her care, which Lucy’s mother, Michelle, described as “hostile”, and Lucy and her family were given a discharge date, without any prior notice or efforts being made to agree it.
Lucy was ultimately discharged back home on November 27 but was admitted as a voluntary inpatient to the Riverside Unit in Bristol on December 12, following a “risk incident” at home.
The jury found that the failures of the unit to adhere to Lucy’s observation levels on the morning of the final incident, December 27, and time lost before emergency treatment started, also “possibly contributed” to her death.
‘Fatal mistakes’
In a statement, Lucy’s parents Michelle and Barry said: “Although fatal mistakes were made on December 27, we don’t blame the staff on the ground.
“To understand what happened that day, you need to look at the wider picture, and it is clear from the jury’s findings that there were failures long before that day.
“First, we need to look at the wider picture of conditions at Riverside, and the findings of an independent review which took place following Lucy’s death, which brought to light a culture of bullying and of management not listening to staff who raised safety concerns.
“Second, is the story of Lucy’s catastrophic journey through mental health services. From January until August of 2023 Lucy did exactly what we teach young people to do when they’re struggling.
“She reached out to adults and professionals around her, and shared with them her darkest thoughts.
“Instead of delivering support, the system seemed focussed around gate keeping and waiting lists.
“When help finally came, it was too late.”
NHS Trust: ‘We failed’
A spokesperson for Avon and Wiltshire Mental Health Partnership NHS Trust said: “We are deeply sorry for the failures in Lucy’s care that contributed to her death.
“Lucy should have been safe in our care, and we failed in that duty. We accept the inquest’s conclusions in full.
“Following Lucy’s death, the Riverside Unit was closed temporarily and remains so.
“We are assessing options for a new inpatient CAMHS unit, and the lessons from Lucy’s death will be central to its design.
“We also acknowledge that Lucy’s care across the wider CAMHS pathway before her admission to Riverside fell short of the standards she and her family deserved, and we continue working with partners to ensure safe, effective services for local young people.”