Clare Langford, a partner in our medical negligence team, secured £20,000 in compensation for the family of a young male following the failure to detain him under the Mental Health Act, leading to his tragic suicide.
Charles* had a history of mental health concerns dating back to school. He attended mainstream school and had to have a statement of educational needs in place. The school had concerns about his challenging behaviour, and some learning difficulties were identified.
Charles was first referred to Child Adolescent Mental Health Service ("CAMHS") in February 2009, presenting with several habits and rituals, low mood and suicidal ideation. Following this, a child-in-need plan was triggered to be put in place by the Local Authority.
Whilst under the care of the Child Adolescent Mental Health Service, various diagnoses were considered, including depression, attention deficit hyperactivity disorder, autistic spectrum disorder (ASD), learning difficulties, oppositional defiant disorder and obsessional-compulsive disorder.
On 13th September 2011, Charles was admitted to the Ashfield Younger Persons Assessment Unit in Birmingham under Section 2 of the Mental Health Act 1983. The admission followed a reported deterioration in his symptoms, including threats to end his life and expressing thoughts of hurting his younger siblings and mother.
In November 2012, he was accommodated under Section 20 of The Children Act 1989 and, in 2013, placed on a care order. In June 2014, he was discharged back to the care of the GP as several attempts had been made to engage the social care placement and social worker without success.
The safety investigation report could find no further evidence of a formal referral or transition from the Child Adolescent Mental Health Service to Adult Mental Health Services. In 2014, there was a potential missed opportunity for the Child Adolescent Mental Health Service to support a safe, effective transition to Adult Mental Health Services.
Charles had reported three unsuccessful attempts to hang himself using a bed sheet tied as a ligature to his weights equipment. He had presented on three occasions throughout the day, and on each occasion, he absconded the department before being assessed. The police were called for his safety and well-being.
In September 2020, his Mum called requesting support to bring Charles' Mental Health Assessment Service appointment scheduled for September 2020 forward as it was too far away. She expressed concern for his potential risk to himself; he had informed his sister if he had a gun, he would shoot himself. She was advised to take him to Accident and Emergency for assessment. However, the response was that Charles would not go.
On this occasion, the investigating team concluded there was a missed opportunity on 3rd September 2020 to redirect the reported deteriorating risks and appointment request via the appropriate crisis routes. Effective communication pathways and proactive response from the Mental Health Assessment Service would have enabled escalation to the responsible clinician and consideration of alternative crisis interventions available to mitigate the reported presenting risks.
The last known contact with Charles was around 9pm on Saturday 5th September 2020. When his Mum had not heard from him, she visited his property on 7th September, as she was concerned for his welfare. Charles was discovered hanging and confirmed deceased at the scene.
How we made a positive impact in this case
Charles's Mum initially contacted us in September 2020, and we were formally instructed on 20th April 2021 to pursue the claim on her behalf.
Initial steps included obtaining all relevant records. Then, we approached medical experts to prepare a breach and causation report. The medical evidence needed to prove this case was obtained from medical experts who supported the matter.
In their opinion, if the 'correct' treatment had been offered between June 2020 and September 2020, on balance, then Charles would have received a higher level of support and treatment. This may have involved admission to a psychiatric unit to maintain his safety or as a brief crisis admission. This would have left him feeling more supported by services, but there would have been active treatment of his depressive episode, a possible emerging psychotic illness and his personality issues with appropriate medication or therapy.
Despite the difficulties faced with the defendants, the defendants admitted breach of negligence, but causation was disputed. We explored the possibility of continuously reaching a settlement with the defendants.
The outcome
A settlement was reached through an offer following negotiations with the defendant's solicitor. The settlement total was £20,000.
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