Mia, 12, was failed by medics before taking her life, inquest finds: Heartbroken mother says she 'will never forgive' the NHS
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The mother of a schoolgirl who took her own life after she was sectioned says she will never forgive the mental health unit or hospital for its failings.
Chloe Hayes was speaking just minutes after an inquest jury delivered its damning findings into her daughter Mia Lucas's death.
The jury found that inadequate testing at Queen's Medical Centre (QMC) in Nottingham 'possibly contributed' to the 12-year-old killing herself. Further tests would have found Mia had an underlying brain disorder.
Speaking this afternoon, mum Chloe criticised the NHS hospital for a 'failure to provide appropriate care' for her girl in her 'time of need'.
Mia was found unresponsive in her room at the Becton Centre, which is part of Sheffield Children's Hospital, on January 29, 2024.
She was suffering from undiagnosed autoimmune encephalitis, a swelling of the brain which would have been the cause of the acute psychosis she was exhibiting, jurors heard.
This diagnosis only emerged partway 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 gathered in the public gallery.
On Thursday, the jury found that the failure to undertake a lumbar puncture at QMC before her transfer to the Becton Centre 'possibly contributed to Mia's death'.
Mia Lucas, 12, was admitted to hospital in 2023 after she started 'hearing voices', tragically dying less than three weeks after being transferred to a specialist unit for treatment
Mia, pictured with her mother, Chloe Hayes, 33, who has fought for justice for her daughter
The 12-year-old was suffering from an underlying brain condition
The jury also concluded there was a failure at the Becton Centre to respond adequately to Mia's risk of self-harm.
In a statement after the inquest, mum Chloe said: '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.
'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.'
Chloe continued: '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.'
The heartbroken mum said the Becton Centre 'proved to be completely unsuitable for her, and one which failed to keep her safe'.
She added: '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.'
Chloe 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'.
Mia was a 'joyous, happy girl', according to her mother
The youngster was found unresponsive in her room at the Becton Centre, which is part of Sheffield Children's Hospital, on January 29, 2024
She said she was 'happy, fun, friendly girl who had so much to live for'.
The inquest heard how 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 was also sectioned under the Mental Health Act.
The jury of five women and four men heard how blood tests and an MRI scan were undertaken at QMC. As a result, doctors ruled out a physical cause of Mia's psychosis.
Medics at Nottingham then 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. She died three weeks later.
In a narrative conclusion, the jury found the failure to undertake a lumbar puncture while Mia was at Queen's Medical Centre 'meant that potential indicators of autoimmune encephalitis were missed'.
It added: 'This possibly contributed to Mia's death.'
Chloe said: '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'
On Thursday, the jury found that the failure to undertake a lumbar puncture at QMC before her transfer to the Becton Centre 'possibly contributed to Mia's death'
Chloe said Mia was 'let down at the Queen's Medical Centre in Nottingham'
The jury added that 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.
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.
The coroner said there was not enough evidence for the jury to find staff handovers on January 29 contributed to Mia's death
Dr Manjeet Shehmar said lumbar punctures would now be performed 'in all future cases of suspected possible autoimmune encephalitis'
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.
Chloe'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.'
Afterwards, Dr Manjeet Shehmar, medical director at Nottingham University Hospitals NHS Trust, which runs QMC, offered 'heartfelt condolences' to Mia’s family and apologised for the failure to diagnose autoimmune encephalitis.
'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,' he said.
Dr Shehmar said lumbar punctures would now be performed 'in all future cases of suspected possible autoimmune encephalitis'.
Dr Jeff Perring, executive medical director at Sheffield Children’s NHS Foundation Trust, said: 'Our thoughts are with Mia’s family and everyone who is grieving her loss in such tragic circumstances.
'We are deeply sorry for Mia's death and recognise the profound impact this has had on those who loved her.'
He said 'significant changes' had been made at the Becton Centre since January 2024 but that the trust would 'carefully reflect' on the conclusions.
- For confidential support call the Samaritans on 116123 or visit a local Samaritans branch, see www.samaritans.org for details
