Inquest finds Priory ‘neglect’ contributed to death of vulnerable 14 year-old girl

A 14-year-old girl suffered an accidental death contributed to by neglect while under the care of the Priory, an inquest jury has ruled.

Amy El-Keria died after tying a scarf around her neck while receiving treatment at the Priory, which runs mental health services as part of a contract with the NHS.

The teenager, who had told staff on the day she died that she wished to end her life, was found in her room at Ticehurst House in East Sussex in November 2012.

Delivering findings that are highly critical of the Priory, a jury in Horsham said she died of unintended consequences of a deliberate act, contributed to by neglect.

It ruled that staff failed to dial 999 quickly enough, failed to call a doctor promptly and were not trained in cardiopulmonary resuscitation (CPR).

The response of staff was so inadequate that the jury agreed there was a possibility that Amy may have lived if she had received proper care.

It said staffing levels were not adequate, and a lack of one-to-one time caused or contributed to Amy’s death in a “significant” way.

Risk assessments were not properly carried out, staff did not assess the risk of her being able to take her own life in her room and opportunities were missed to remove the scarf from Amy, all causing or contributing “significantly” to her death.

The jury also said the Priory failed to properly deal with the fact that Amy was being bullied, and staff failed to share details of the times the teenager had said she wanted to kill herself.

A delay in checking on her on the evening she died also contributed significantly to her death, while she should have been under even closer scrutiny, it said.

The jury, sitting at Horsham Coroner’s Court, heard that staff were not trained in resuscitation techniques, despite one healthcare assistant asking for training, and did not always tell parents when their children were being forcibly sedated.

Amy, who had a complex range of problems and mental health diagnoses, including attention deficit hyperactivity disorder (ADHD), Tourette’s, oppositional defiant disorder (ODD), gender identity dysphoria and conduct disorder, was moved to the Priory in August 2012 after being asked to leave her specialist boarding school, High Close in Berkshire.

The inquest heard that, while at school, she had drawn a picture of herself hanging and had written underneath: “If only this could happen, but I haven’t got the guts.”

Several attempts to end her life followed throughout early 2012 before Amy was admitted as a “nervous” inpatient to Ticehurst House, following a referral by West London Mental Health NHS Trust.

She was deemed high-risk and put on 15-minute observations, and forcibly sedated on at least two occasions.

On October 27, a football scarf was seen in her room but staff from the Priory admitted at the inquest that it was not taken away and the hospital had no list of banned items.

Just over two weeks later, on the day she died – with her risk rating now downgraded to medium – Amy told a member of staff she wanted to kill herself.

Later that evening, a member of staff found her door locked and realised Amy had decided to try to end her life.

The inquest heard that, before an ambulance arrived, an oxygen mask was put over Amy’s face which did not fit and there was a “high level of anxiety among the team”.

She was not resuscitated properly by staff, was vomiting profusely and had to be removed from the hospital on a body board because the ambulance stretcher would not fit in the hospital lift.

Earlier in the inquest, Priory staff said that, due to pressure on wards, they had not always been able to give the teenager one-to-one time.

The jury also heard from West Sussex senior coroner Penelope Schofield, while summing up the evidence, that one member of senior staff had “put on training on Tourette’s but nobody had attended”.

A more junior member of staff had asked the ward manager for CPR training “but had got no response”.

Dr Sylvia Tang, Priory Group medical director, said: “We would like to offer an unreserved apology and our heartfelt sympathies to Amy’s family.

“Following the incident, we undertook an extensive investigation and strengthened a number of our procedures at the hospital.

“We will now review the findings of the inquest very carefully and consider whether further improvements can be made including in relation to staffing, care plans and risk assessments.

“Since the incident took place, we have been re-inspected by the independent Care Quality Commission which has confirmed the hospital is meeting all national standards.”

The inquest heard of several incidents where Amy was physically restrained by staff, sometimes for 15 minutes at a time.

The last incident occurred the day before her death, when Amy was restrained by five members of staff for 15 minutes and orally sedated.

The jury also heard the Priory had a high reliance on agency staff including some with no psychiatric experience, and insufficient time to read patients’ paperwork or clinical notes.

Amy’s mother, Tania El-Keria, said: “Amy was my most loved youngest daughter, sister, niece and granddaughter with her whole life ahead of her. She had a warm heart and a great sense of humour. She never liked to see people treated unfairly and would be the first to stand and say ‘that’s not right’.

“For 14 years we kept Amy safe. In less than three months under the care of the Priory she was dead. The only thing that has kept me going since her death nearly four years ago has been the need to achieve justice for my Amy.

“I knew the Priory’s investigation following the death was a whitewash and this inquest has proven that. If I had treated Amy and neglected her needs in the way Ticehurst House did, she would have been taken away from me.

“I don’t blame junior staff for what happened to Amy, I blame the Priory for failing to put in place the systems needed to keep her safe and for ensuring she received the care and treatment she so desperately needed.

“Had she lived, Amy would have turned 18 during this inquest hearing. I am so sad that others will not have the privilege of meeting someone as caring, loving and exceptional as Amy.

“The most important thing to me now is to change the system which is failing to provide the mental health care our children need. I will continue this fight in my Amy’s name.”

Deborah Coles, director of Inquest – which has supported Amy’s family since her death, said: “The jury findings are an indictment of a mental health system that placed a child far away from home, in a private unit operating dangerous and grossly inadequate systems of care

“The desperate catalogue of failings exposed at this inquest all point to a system that is shamefully failing our responsibilities of care for vulnerable children.

“This evidence has only been exposed now, four years after Amy’s death, as a result of the family’s fight for a full inquest with a jury, resisted by the Priory.

“The only possible response to this case and the growing public outcry around mental health services for children and young people is for an urgent independent review. We call upon the Government to now take this necessary step.”

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