Essex mental health services failings linked to death of 16-year-old girl, inquiry finds
A coroner's report has suggested Elise Sebastian's death could have been prevented.
A future deaths report opens up concerns regarding significant failings by Essex mental health services in the case of 16-year-old Elise Sebastian.
Elise, who had autism, died on 19th April 2021 at Colchester Hospital, following a suicide attempt while she was a patient at St Aubyn’s Centre in Colchester.
A jury determined that her death could have been prevented if not for multiple issues in her care, including poorly handled observations due to low staffing levels and falsified observation forms.
There were also concerns about Elise accessing her room alone.
Coroner Sonia Hayes noted staff at St Aubyn’s Centre were untrained in autism, inexperienced, and often new bank and agency staff, which contributed to insufficient observations required for patients.
The Lampard Inquiry heard from Elise’s mother, Victoria, expressing the profound impact of her daughter's death on their family.
“Losing Elise has shattered my life. My family is shattered. The loss is so heart-breaking and painful that I can’t begin to describe it in words,” she said.
The report highlighted staffing issues, suggesting that allocated staff were required to conduct approximately 66 observations within an hour, which was not feasible.
The implementation of the remote monitoring system Oxevision faced difficulties due to WiFi coverage and operational issues.
Medication changes for Elise were inadequately recorded, and eliminations from her prescription chart were not queried by nursing staff.
The report noted Elise's mental health had deteriorated significantly, with an increase in the frequency and severity of ligatures.
Errors in medication management were only identified when questioned by Elise’s family.
Furthermore, inadequate communication between ward staff led to vital information about self-harm not being passed as shifts changed.
Mental Health Trust staff had falsified Elise’s observation records, undetected until post-death investigation.
At 6.10pm, Elise was seen entering her bedroom, where she stayed until found unresponsive at 6.29pm, despite a requirement for constant observation.
Alex Green, Deputy Chief Executive of Essex Partnership University NHS Foundation Trust (EPUT), stated: “I want to say sorry to Elise’s family and to everyone who loved her that she did not receive the care she deserved, and I offer my deepest condolences. We will review the Coroner’s report in full and will respond.”