12-year-old girl took her own life due to an undiagnosed brain disorder - "I will never forgive medics" mother says
A 12-year-old girl took her own life due to an undiagnosed brain disorder - with her devastated mother saying she will never forgive the medics who missed it.
An inquest ruled Mia Lucas died after a “failure to provide appropriate care to her in her time of need”, finding inadequate testing at the Queen’s Medical Centre (QMC) in Nottingham “possibly contributed” to her death. Her mother, Chloe Hayes, has received an apology from the QMC, but said she could not get over the loss of her “beautiful little girl”.
Mia was found unresponsive in her room at the Becton Centre, part of Sheffield Children’s Hospital, on January 29 last year, having been sectioned weeks earlier. Jurors heard how Mia was suffering from undiagnosed autoimmune encephalitis - a swelling of the brain - which would have been the cause of the acute psychosis she was exhibiting.
The diagnosis only emerged part-way through the nine-day long inquest, after a pathologist revealed she had just received new post-mortem examination test results, provoking shock in the courtroom and tears among Mia’s relatives.
On Thursday, the jury found a failure to undertake a lumbar puncture at QMC before her transfer to the Becton Centre “possibly contributed to Mia’s death”. The jury also said there was a failure at the Becton Centre to respond adequately to Mia’s risk of self-harm.
In a statement after the inquest, Mrs Hayes said: “It has been devastating to listen to how, when she needed specialist healthcare, for the first time in her life, she was so badly let down. She was let down at the Queen’s Medical Centre in Nottingham, who wrongly decided there was no underlying physical cause of her psychosis, and failed to carry out appropriate testing.
“I believe they simply dismissed her and looked to pass her onto mental health services as quickly as possible, which led to her transfer to the Becton centre.”
“Her mental health spiralled deeper out of control there, as she was not being treated for her condition, and the many failings and lack of care meant sadly she wasn’t properly protected from harming herself,” she added. “My beautiful little girl has lost her life and I will never forgive the Queen’s Medical Centre or the Becton Centre for failing her.”
Mrs Hayes said the Becton Centre “proved to be completely unsuitable for her, and one which failed to keep her safe”, adding: “I have never believed for a moment that Mia ever wanted to take her own life. She was always a happy, healthy child and had so much to live for.”
Mrs Hayes said she wanted everyone to know that Mia’s extreme behaviour was only evident in the final few weeks of her life and “for the other 12 years, she was a beautiful soul who loved life and loved her family, and that’s how we want her to be remembered”, as a “happy, fun, friendly girl who had so much to live for”.
The inquest heard Mia began to behave strangely over Christmas 2023 – including hearing voices and attacking her mother – and her family became so concerned she was taken by ambulance to QMC on New Year’s Eve. She was found to be experiencing an “acute psychotic episode” and sectioned under the Mental Health Act.
The jury of five women and four men heard how blood tests and an MRI scan were untaken at QMC which were found to be negative and doctors ruled out a physical cause of Mia’s psychosis. But doctors at Nottingham decided not to order further tests on brain wave function and spinal fluid, through a lumbar puncture, which may have revealed the autoimmune encephalitis, which is very rare.
Mia was transferred to the Becton Centre on January 9 and died three weeks later.
In a narrative conclusion, the jury said: “The failure to undertake a lumbar puncture at this point (at QMC) meant that potential indicators of autoimmune encephalitis were missed. This possibly contributed to Mia’s death.”
The jury added the information passed between QMC and the Becton Centre “provided an inappropriate level of assurance that organic causes had been ruled out”.
In relation to the Becton Centre, the jury concluded that: “Insufficiently robust communication and management of risk led to a failure to respond adequately to Mia’s risk of self-harm.”
The jury also said that a “rare presentation of a rare condition” provided “particularly complex challenges” for diagnosis and care.
The jurors found, on the directions of the senior Sheffield coroner Tanyka Rawden, that Mia’s cause of death was “compression of the neck”, caused by “acute psychosis”, caused by “autoimmune encephalitis”.
They heard how Mia self-harmed in her three weeks at the Becton Centre, but the coroner said there was not enough evidence for the jury to find staff handovers on January 29 contributed to Mia’s death.
Mrs Rawden said she will be writing to Health Secretary Wes Streeting, along with a number of professional bodies, about her concerns about the lack of national guidance over testing for autoimmune encephalitis. She said she was satisfied she did not need to write to Sheffield Children’s Hospital after hearing about a range of changes at the Becton Centre.
And Mrs Rawden said she would wait six months, to let Nottingham University Hospitals finish its own investigation, before considering a letter to that trust.
Ms Hayes’s solicitor Amy Rossall, of Hudgell Solicitors, said: “We’ve heard many comments about lessons being learned as a result of what happened to Mia, and those learnings will hopefully help to avoid other families losing their children to the condition.”
Dr Manjeet Shehmar, medical director at Nottingham University Hospitals NHS Trust (NUH), said: “We accept the coroner’s outcome in court today and apologise to Mia’s family for not identifying autoimmune encephalitis while she was in our care. While this is an incredibly rare condition and initial tests were negative, we recognise that further testing may have had an impact on her future, for which we are truly sorry.”
Dr Jeff Perring, executive medical director at Sheffield Children’s NHS Foundation Trust, said: “We are deeply sorry for Mia’s death and recognise the profound impact this has had on those who loved her.”
Dr Perring outlined the changes made at the Becton Centre following a review of Mia’s care and said a CQC inspection in September found it to be “safe and staff there caring and responsive to patient needs”.