A senior coroner has said we are “failing” our young people after a teenage girl was denied personal appointments before committing suicide during lockdown.
Penelope Schofield warned there is a “clear risk” that young people will succumb to mental illness if urgent action is not taken, as she announced she wrote to the health minister Sajid Javid.
The coroner concluded that Robyn Skilton, 14, committed suicide after being let down by “gross failures” in the NHS.
The failures were so severe in the case of the suicidal teenager – who was constantly rejected for assessments – that Ms Schofield ruled the NHS was guilty of “neglect”.
Robyn, from Horsham in West Sussex, disappeared from her £670,000 family home and hanged herself in a park on May 7 last year, with a long history of self-harm and a desire to commit suicide.
At the time, England was on step two of the government’s roadmap out of lockdown and no in-house mixing was allowed.
Despite “really serious concerns” about her mental health, Robyn did not receive a personal consultation, was not seen by a child psychiatrist or assessed for mental health problems and was discharged from an NHS service a month before her suicide, despite being on his “red list”. with a high risk.
She was referred to a council support program but was put on a ten-month waiting list for a one-on-one consultation.
In the end, when she had a consultation, it was just a remote session due to the pandemic.
Robyn’s father Alan Skilton, director of a software company, constantly pleaded with authorities for help.
‘Amazing’ lack of care
He told his daughter’s inquest that the lack of care she received was “astonishing.”
Ms Schofield, who has led a number of high-profile investigations, including the Shoreham Airshow disaster, announced she would write a report to the government after the hearing.
“As a society we are failing young people,” Ms Schofield warned.
Ms Schofield said she was “shocked” to hear evidence during the two-day hearing that the number of young people seeking help in mental health care has increased by 95 percent in recent times.
She said: “If we try to manage it without more resources, we’re not giving the help that young people need.
“Robin’s case is proof of that.
“It’s a clear risk that more lives will be lost if we don’t do something about it.
“Therefore, I will write a report for the prevention of future deaths to the Minister of Health to address these concerns.”
Ms Schofield added that young people ‘need resources to get the help they need’.
Ms Schofield ruled there were ‘gross failures’ by Sussex Partnership NHS Foundation Trust in the case of Robyn and the Trust’s Sussex Child and Adolescent Mental Health Service [CAMHS]†
‘I must come to a conclusion of neglect’
She said: “I appreciate the landscape in which the Trust worked as Covid-19 increased the level of complexity, but there were many shortcomings in the care of Robyn.
“The totality of these failures, in my view, means that I must conclude that I have been neglected. There was a gross negligence in providing care to someone in a dependent state.
“Robyn took her own life as she struggled with her mental health.
“Mental health services failed Robyn because they failed to recognize the deterioration of her mental health, nor did they give her the care she needed.
“Her death was also caused by neglect.”
dr. Alison Wallis, the clinical director of the Children’s Services Trust, tearfully told Robyn’s parents ‘you didn’t get the service you deserved’ and that Covid was affecting their care.
Ms. Schofield outlined the main shortcomings.
‘We did everything we could to help’
These include CAMHS’s failure to rate its “good or not at all”, leading to missed opportunities to address its “escalating needs” over several years, but “particularly April 2021 when it was clear that there was a risk to the was life”.
Ms Schofield said no face-to-face consultations had been arranged, a lack of direct communication, a failure to offer her CAMHS treatment when she met the criteria, and a failure “to have Robyn assessed at any time.” “.
She ruled that the “decision to discharge her from CAMHS and instead continue treatment for autism was inappropriate” and that Robyn should have seen a child psychiatrist.
Robyn’s father, who attended the Chichester inquest with his wife and Robyn’s mother, Victoria, said that “we tried everything we could to help the teenager”.
He said: “We do believe that if Robyn had been seen well before … her mental health would have improved and she would not have committed suicide.”
Robyn was “outgoing, sociable and made friends easily”, loved ballet, gymnastics and swimming, and was “artistic by nature” and loved to sing and dance.
However, her problems started in late 2018, after she moved to the Mallais School for girls in Horsham the year before.
hearing voices
Robyn developed mental health problems, repeatedly self-harmed, attempted suicide and was hospitalized four times. She later told the doctors that she heard voices and saw images.
She was referred to the West Sussex County Council’s Youth Emotional Support Service and attended group sessions, but they did not offer her support and was placed on a waiting list for 10 months for a one-on-one consultation.
In the end, when she had a consultation, it was ineffective because it was remote due to the pandemic.
CAMHS wouldn’t hire her initially, even though she met the criteria, and when the service did, it focused on trying to assess her for autism.
Her parents were told that self-harm was a “coping mechanism”, Robyn did not receive bi-weekly checkups, and she was not addressed directly by CAMHS.
Mr Skilton was “shocked” Robyn was given a self-questionnaire to complete when she was suicidal and was repeatedly frustrated at not being kept in the dark by authorities due to “confidentiality”.
‘Our pleas were rejected’
“The hospital just seemed to be doing a tick-box exercise to get her fired,” Mr Skilton claimed. “Even when she threatened to jump off a bridge, our requests for help were denied.”
Robyn said that “no one could help her” and that she was “looking forward to ending her life.”
In early 2021, she was rushed to hospital for attempting an overdose of paracetamol and stayed for three nights. Mr Skilton said: “We were surprised that after she attempted suicide she left the hospital with less support.
“No one seemed to take her mental health seriously.”
Mr and Mrs Skilton became “desperate” at the lack of help Robyn received near her death, asked CAMHS if she could be placed in autopsy and considered admitting her to the Priory at £1,300 a night.
Mr Skilton said in the days before her death “her mood completely changed” and it gave her parents “false hope”.
Missed opportunities
Attorney Rebecca Agnew, of Sussex Partnership NHS Foundation Trust, admitted that “CAMHS was not assessing Robyn appropriately, leading to missed opportunities for her escalating needs”.
She added: “The Trust offers its parents a formal apology for these shortcomings.
“The Trust failed to adequately assess Robyn and provide her with the care and assistance she required and this contributed more than minimally, trivially or negligently to Robyn’s death.”
Carly Mendy, senior practitioner of CAMHS, admitted as proof, “It was inappropriate to fire her from the service.”
CAMHS clinical specialist Velani Bhebhe admitted that their risk assessment of Robyn was “not detailed enough”.
Sussex NHS Trust has begun making major changes to its mental health services and Ms Schofield will reconvene the inquiry in three months to review them.