Nadia Shah inquest: Teen's death contributed to by inadequate care

Nadia Shah's sister described her as "loyal, brave and selfless"

Inadequate care at a mental health clinic contributed to the death of a teenager detained there, a jury said.

Nadia Shah, 16, from Cambridge, died while being detained under the Mental Health Act at Potters Bar Clinic, Hertfordshire, in January 2019.

An inquest jury found multiple failures in her care, including issues around observations and her care plan.

Elysium Healthcare, which runs the clinic, apologised for the "shortcomings in care".

Her father, Alkesh Shah, said: "The job of the staff was to keep my daughter safe and I feel totally let down by what happened.

"Things could have turned out so differently that day, and while nothing will ever bring Nadia back to me, all I hope for now is that something is learned from my tragedy.

"I wouldn't want anyone else to go through what I have."

Her mother, Lorraine Shah, added: "The jury's conclusion shows that it is not safe for the NHS to place a child at risk of self-harm like Nadia at Elysium."

The coroner's court heard that the teenager, who had complex post-traumatic stress disorder with psychotic features, was "deemed to be a risk to herself".

She had been at clinic since October 2018, and at the time of her death she was being "observed four times an hour".

Nadia Shah was a "beautiful young girl with a heart of gold", her father said

Nadia had returned to the clinic from home leave on 12 January, but at 15:15 GMT was found unresponsive.

She died three days later at Barnet General Hospital, having suffered an "unsurvivable brain injury".

Her father, Alkesh Shah, had previously told the inquest jury he "never believed" she intended to take her own life.

He said his daughter gave no indication she would self-harm or attempt to take her own life and he had taken her back to the clinic that day.

The Potters Bar Clinic is run by Elysium Healthcare

The jury concluded she died as a result of "misadventure, contributed to by the inadequate care at the Potters Bar Clinic".

"There was an unsatisfactory implementation of the care plan and a failure to sufficiently engage and provide cohesive care," the jury said.

"The emergency and resuscitation response was lacking and CPR was not carried out properly by the clinic staff."

They added there was "a lack of clarity around the application of the observation policy" and a "failure to report observations to properly inform assessment of risk".

Catherine Knight, from Mr Shah's legal team Irwin Mitchell, said: "What makes this case all the more heart-breaking is that this is not the first time that Elysium Healthcare has been the focus of investigation, and it's vital that this time lessons are learned to improve patient safety and help prevent others from suffering similarly in the future."

Elysium Healthcare said in a statement: "This was an utterly tragic incident, and we apologise wholeheartedly for the shortcomings in care identified by the inquest.

"As a direct result of Nadia's death, we immediately undertook a full review of our policies and procedures regarding patient observations and the training and delivery of life-saving measures. Crucially, we have increased the number of life support drills for all team members.

"These important learnings have also been shared throughout our services in the years since this tragic incident.

"As ever, our thoughts and prayers remain with Nadia's family and friends."