Multiple NHS failings contributed to child’s suicide, inquest told

An NHS trust has vowed to improve after its “multiple failings” contributed to the suicide of a 12-year-old girl, an inquest was told.

Allison Aules had been under the care of North East London NHS Foundation Trust (NELFT) when she died in July 2021.

She had been referred to a mental health team in May 2021 over concerns about self-harming and low moods, but an “essential” face-to-face assessment was never conducted, coroner Nadia Persaud said.

The assessor instead spoke with Allison and her mother over the phone and did not appear to determine the cause of the preadolescent’s “worrying presentation”.

Allison was discharged from the service without a multidisciplinary review and was found dead four days after her school counselling sessions ended.

It had taken nine months for her to be seen and she had been initially screened as low-risk, which pointed to quality issues in the council’s health provision, the coroner said.

NHS North East London has since committed to improving and is developing a plan for better investment, officials told a meeting of Redbridge Council’s health and wellbeing board on Monday April 22.

In response to the inquest’s findings, a ‘steering group’ – comprising professionals from young people’s services, NELFT, and Redbridge Council – acknowledged the need to address not only the volume of referrals but the root causes.

It said that could be achieved by offering earlier access to specialist support, maximising provisions for communities, and better “integrated working” between groups.

The group also hired an additional consultant psychiatrist to focus on initial assessments and offer urgent medical reviews and treatments.

The inquest, held in August 2023, heard how the borough’s health service was “significantly under-resourced” compared to others and that children’s services had been historically underfunded for “unexplained reasons”.

Redbridge’s Child and Adolescent Mental Health Services (CAMHS) is the smallest in north east London.

The number of psychiatrists working at the service is currently based on the number of referrals made in 2010, a report before the council said.

Back then, it received between ten and twelve a week. Fourteen years on, the current number is around 140.

In the report, a representative from the integrated care board said such a mechanism was “not indicative” of current levels of demand.

Last week, councillors said almost a fifth of children aged between eleven and 17 in north, central, and east London have a diagnosable mental health condition.

That marks a 23% increase from 2019, according to the latest NHS data.

Levels of “high deprivation” and “preexisting equalities” have exacerbated mental health issues in Redbridge, according to the council’s children and young people policy development committee.

Social isolation during the Covid-19 lockdowns in 2020/21 has been partly responsible, alongside perceived difficulties in reaching out to trusted adults, and pressures being put on young carers.

In some teens, there is a reluctance to access services out of fear of being bullied, the committee said.

Sebastian Mann

Local democracy reporter