A susceptible 14-year-old lady was unlawfully killed when an company assist employee did not maintain her below commentary at a safe psychiatric unit, an inquest jury has concluded.
The employee, who used a false id, left Ruth Szymankiewicz alone although she had complicated psychological well being points and was judged to want fixed watching as a result of she was a suicide threat.
Ruth was in a position to slip again to her room and harmed herself on the privately run Huntercombe hospital close to Maidenhead on 12 February 2022. She died two days later.
In the course of the inquest it emerged that the employee, who went below the stolen id Ebo Acheampong, had by no means labored at any hospital earlier than the day he was put in control of observing Ruth and didn’t obtain an induction earlier than his shift.
The jury at Beaconsfield raised considerations about coaching of company workers at Huntercombe and stated contributing components to Ruth’s dying included her not being prevented from accessing the fabric she used to hurt herself.
She didn’t obtain remedy which will have helped whereas she was being detained below the Psychological Well being Act, household visits have been restricted although they could have helped her wellbeing and he or she was in a position to entry dangerous materials on her telephone, the jury heard.
Talking after the jury returned its findings, Ruth’s mother and father, Kate and Mark Szymankiewicz, who’re respectively a GP and a advisor surgeon from Wiltshire, stated: “There is an empty space at our table, a silent bedroom in our home, a gaping hole in our family that will never be filled.
“Ruth was an incredible, bright, friendly, loving and adventurous girl with a whole life of joy ahead of her. She, like many other teenagers, developed an eating disorder.
“When, at our most vulnerable as a family, we reached out for help, we ultimately found ourselves trapped in a system that was meant to care for her, to help her, to keep her safe, but instead locked her away and harmed her. As a child who thrived on her connection with nature, she was essentially caged.
“Over the last two weeks, we have heard about the numerous systemic failures at Huntercombe hospital,” the household stated. “It would be easy to be distracted by the failings of one individual. However shocking that conduct might have been, it is paramount that the other wider and more important issues are acknowledged and addressed.”
Well being specialists advised the Guardian that most of the points round using company workers and the scarcity of psychiatric intensive care items for youngsters and younger folks was nonetheless an enormous drawback.
Andrew Molodynski, the British Medical Affiliation’s psychological well being lead, stated there was a “gap in accountability” over the coaching and vetting of company workers. He stated it was usually psychological well being inpatient items, with probably the most high-risk people, that relied on company workers probably the most, particularly after they had sufferers like Ruth needing one-to-one supervision.
He stated this was a “toxic catch-22 … You end up with very few people who know the ward and know the patients”.
Minesh Patel, an affiliate director of coverage and campaigns on the psychological well being charity Thoughts, stated Ruth’s case was “a clearcut example of the many systemic issues in our mental health hospitals”.
He stated: “An overreliance on agency staff can compromise patient safety, quality of care, and in the worst cases lead to serious harm or loss of life.”
In the course of the inquest, Dr Gillian Combe, the scientific director for the supplier group that commissioned Ruth’s placement, stated the understaffing seen at Huntercombe nonetheless existed.
She expressed frustration at guidelines in England that make it laborious for brand new NHS items to be constructed, which means supplier teams need to depend on sending sufferers to personal items.
Combe stated this example arose after Andrew Lansley’s adjustments to the NHS – described by some as “creeping privatisation” – when he was the well being secretary from 2010 to 2012. She stated there have been no psychiatric intensive care items for youngsters and younger folks in the entire of south-west England.
Jodie Anderson, a senior caseworker on the charity Inquest, stated: “The jury’s findings are a stark indictment of a mental health system that sent a vulnerable child far from home to a private unit with dangerously inadequate care.”
Dr Amit Chatterjee, the chief medical officer at Lively Care Group, which owned and ran Huntercombe, advised the inquest that the corporate had labored laborious to enhance recruitment and its induction course of.
Huntercombe has closed however Chatterjee stated the corporate had elevated therapeutic care at its present website for younger folks, Ivetsey Financial institution hospital in Staffordshire.
The inquest heard that after studying that Ruth had died, the employee often called Acheampong fled from the UK to Ghana. Thames Valley police stated they knew his actual id however didn’t have sufficient proof to attempt to get him again.
Using company workers in psychological well being settings has been cited as a giant drawback in quite a few opinions and inquest conclusions. Within the case of Lily Lucas, a 28-year-old girl who died in 2022 from extreme fluid consumption introduced on by schizophrenia, an NHS overview discovered that some company nurses on her privately run ward didn’t know easy methods to use 999.
A Care High quality Fee report on the Psychological Well being Act stated sufferers had described company workers as “not friendly” and “less caring” in direction of sufferers, and detrimental to morale amongst everlasting workers.
