A coroner is demanding more action should be taken by an NHS Trust mental health service after a 13-year-old girl took her own life.
Senior Coroner Professor Paul Marks, area coroner for Hull and the East Riding, has highlighted the faults of Humber Teaching NHS Foundation Trusts’ helpline after a teen girl using the services took her own life. This comes after the inquest of 13-year-old Eden Street, who had committed suicide while waiting to start creative therapy. The coroner began the investigation into the death of Eden on July 1, 2021 and concluded on December 11, 2024.
Eden Anna Street, who lived in the Market Weighton area, had displayed traits from a very early age which would be consistent with Autism and had several of her family members were also affected with neurodiversity issues. In a report, it said that her mother was ‘concerned’ about her behaviour and communication issues and referrals to the Child and Adolescent Mental Health Services took place, although the first referral was rejected.
Eden was diagnosed with Tourette’s Syndrome and when the diagnosis was made, her tics and involuntary movements improved. She was also on the waiting list for both creative therapy as well as the East Yorkshire Autistic Service.
It said: “She had written on the school lavatory wall which resulted in her mother contacting CAMHS, which occasioned an immediate risk assessment to take place, nothing immediate was identified. A decision was made to expedite the start of creative therapy but due to the practitioner’s care load being full of cases of equal, if not greater acuity, this did not prove possible.”
Sadly on June 27, 2021 she was found unresponsive by her family. Despite the emergency services efforts and continued resuscitation, that had been started by her parents, she could not be revived and was declared deceased. The report later adds: “It is not possible to determine on the evidence available whether earlier diagnosis of Autism or the institution of creative therapy would have avoided her death on the day it occurred.”
During the inquest, it was revealed that information provided by parents of autistic children via a telephone helpline operated by the Trust, was not fed back to the weekly audit meeting convened by the Trust. As a result, information about children with neurodiversity issues that might have altered for the worse, may not be available to those who can alter their clinical priorities.
Coroner Marks concluded that the Trust’s service needs to change to prevent more deaths. He said: “In my opinion action should be taken to prevent future deaths and I believe you and your organisation has the power to take such action.”
He has now given the Trust until March 7, 2025 to come up with an action plan on making the service better. He added: “Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise, you must explain why no action is proposed.”
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