Chance missed to help schoolgirl - coroner

A Suffolk coroner has published a prevention of future deaths report following the death of the 14-year-old girl

A coroner has raised concerns that a hospital's emergency department did not apply guidance that could have helped prevent a girl's death.

Erin Tillsley, 14, from Great Cornard, Suffolk, took her own life in July last year after struggling with her school attendance.

Following an inquest, area coroner for Suffolk, Darren Stewart OBE, said there was a "missed opportunity" to engage early with the teenager when she attended West Suffolk Hospital's emergency department months prior to her death.

West Suffolk Hospital NHS Foundation Trust said it had since ensured all staff were aware of processes within the children's referral pathway.

An inquest into the death of Miss Tillsley concluded on 31 May of this year. Mr Stewart published a Prevention of Future Deaths Report this month.

In his report he detailed that Miss Tillsley had struggled with her school attendance following the Covid-19 pandemic restrictions being lifted in 2022.

At the end of that year she had a difficult period with a friend, and after a self-harm incident, she was taken to West Suffolk Hospital in Bury St Edmunds on 31 December.

Her physical symptoms were assessed but "not considered serious" and she was discharged the following day.

"Emergency department staff at the West Suffolk Hospital did not consider a referral to psychiatric liaison services to be appropriate during the admission; however advice was given for a referral by Erin’s GP to mental health services," Mr Stewart said in his report.

Mr Stuart said there had been a "missed opportunity" for early engagement with Miss Tillsley

Mr Stewart said evidence heard during Miss Tillsley's inquest indicated that guidance was not applied in the care and treatment of the teenager while she was at hospital.

This included National Institute for Health and Care Excellence (NICE) guidance on self-harm as well as guidance from Suffolk and North East Essex and Suffolk County Council's joint policy on how to support children and young people in crisis.

"The failure to apply this guidance/policy meant that there was a missed opportunity for mental health services to engage early with a vulnerable child who had presented to the emergency department having [self-harmed]," Mr Stewart said.

On the day she died, Miss Tillsley was due to start a new school but told her father she would not be attending.

She was later found unresponsive by her father and pronounced dead at the scene by paramedics.

'Deeply saddened'

Dr Ewen Cameron, chief executive for the West Suffolk NHS Foundation Trust, said the trust was "deeply saddened" by Miss Tillsley's death.

"Every patient deserves the highest quality and safest care and we have rightly carried out a patient safety review regarding Erin’s care with us," he added.

He said the trust had received Mr Stewart's report and would be further reviewing its processes.

Since Miss Tillsley's inquest the trust said it had provided ongoing training and education around engaging services from colleagues in its mental health liaison team.

It said it had worked with other organisations in Suffolk and north east Essex to review the protocols around children and young people in crisis.

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