Madeleine Savory: Multiple agency failures contributed to teen's death
Madeleine Savory was on a ward at Ipswich Hospital while waiting for a mental health unit bed to become availableA 15-year-old who died after an attempt to end their life in hospital while waiting for a mental health bed was repeatedly failed, a coroner concluded.The coroner said failures at Ipswich Hospital, Northgate High School and around the availability of mental health beds contributed to their death.
Madeleine, who had a history of self-harm, had been first referred to Norfolk and Suffolk NHS Foundation Trust , which cares for people with their mental health, after a hospital admission in September 2021.Suffolk coroner Darren Stewart said failures at Northgate High School, on Bergholt ward and the acute paediatric ward at Ipswich Hospital, and surrounding the availability of urgent tier four mental health beds for children, all more than minimally contributed to Madeleine's death.
Staff had a "naivety" when it came to children with mental health conditions, he said, adding there was a "failure to implement the relevant policies". But Mr Stewart said the availability of a tier four bed nationally was "at the heart of the inquest".The court was told there was a national shortage, with average wait times in the East of England being 46 days.In a statement, Madeleine's family said they were "heartbroken and devastated".
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