AN NHS trust has admitted it “failed” a teenage patient who died after an incident at a Fishponds mental health unit.
Lucy Curtis, who was 17, died five days after being found unresponsive following a self-harm incident in the Riverside Adolescent Unit at Blackberry Hill Hospital on December 27, 2023.
The unit was run by Avon and Wiltshire Mental Health Partnership NHS Trust (AWP), for patients aged 13 to 18 with “complex and enduring mental health difficulties”. It closed shortly afterwards, and has not reopened.
Lucy’s parents say the sixth-form student’s death was “preventable and avoidable”, and believe she would still be alive had concerns been acted on sooner.
Delivering a narrative conclusion in July, an inquest jury at Avon Coroner’s Court found failures at the unit to adhere to 15-minute check-up intervals on the morning of the incident, and delays in delivering life-saving medical support, “possibly contributed” to Lucy’s death.
The jury also found delays in getting specialist support from Child and Adolescent Mental Health Services (CAMHS) also “possibly contributed” to her death.
Jurors heard Lucy’s contact with mental health services started in January 2023, when she told her GP about anxiety, low mood and self-harm.
Child and Adolescent Mental Health Services (CAMHS) turned down two referrals before adding her to a waiting list four months later. She was only given an initial appointment after an incident in August, which revealed a risk she planned to end her life.
After two more sessions, Lucy went missing from the family home in Almondsbury overnight, and was admitted to a mental health unit in Bridgwater.
While there, Lucy’s self-harm escalated, but the inquest heard it was practice not to remove items used for self-harm if she was not considered to be at immediate risk of serious harm.
This led to an incident in November 2023, where she suffered a significant injury, but Lucy’s family was then given a discharge date, without any effort to agree it.
A fortnight later after returning home she was admitted as a voluntary inpatient to the Riverside Unit, following a “risk incident”.
‘When help finally came, it was too late’
Lucy’s parents Michelle and Barry said: “Although fatal mistakes were made on December 27, we don’t blame the staff on the ground.”
They said failures were made “long before that day”, and pointed to an independent review of Riverside that uncovered a “culture of bullying and of management not listening to staff who raised safety concerns”.
They said Lucy’s “catastrophic journey through mental health services” showed a system focussed on gatekeeping and waiting lists, instead of delivering support, adding: “When help finally came, it was too late.”
NHS trust: ‘We failed’
An AWP spokesperson 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.”
The spokesperson said AWP is “assessing options” for a new inpatient unit to replace Riverside, adding: “The lessons from Lucy’s death will be central to its design.”