Teen died after attempt on own life in Ipswich Hospital - inquest

Madeleine Savory was on a ward at Ipswich Hospital while waiting for a mental health unit bed to become available

A 15-year-old who died after an attempt on their own life in hospital had been waiting for a bed on a mental health unit for two weeks, an inquest heard.

Madeleine Savory was admitted to Ipswich Hospital after self-harming on 3 February 2022.

Despite escalating the bed request after staff raised safety concerns, a bed was not found before their death.

In February 2022, there were 19 young people across NHS East of England region awaiting beds, the court heard.

In a statement when the inquest began on Monday, Madeleine's family said they were "overwhelmed with grief and anger".

Madeleine, who used they/them pronouns, had been under the care of Norfolk & Suffolk NHS Foundation Trust (NSFT) after a referral to mental health services following a hospital admission in September 2021.

They were assessed on 21 October and gender dysphoria, anxiety, low mood and food restriction were identified.

Between September and February, they had several instances of self-harm and their family became increasingly worried about their risk level, Suffolk Coroner's Court heard.

They had self-harmed on 3 February after leaving Northgate High School in Ipswich, but the school did not raise an alarm about their absence for over an hour, the inquest was told.

They were admitted to the hospital and placed on a list for a mental heath unit bed on 7 February.

While waiting for a bed they made an attempt on their life on 19 February and died a week later, the inquest, which began on Monday, heard.

Emma Ellis, who was the community team leader for East Suffolk's children and young team at NSFT said she was "frustrated" when trying to get "tier 4" beds for young people due to bed availability in the region.

She said due to bed closures and the pandemic it had become even harder.

'Significant problem'

The bed application was updated on 14 February following concerns raised by ward staff that they could not keep Madeleine safe after finding items they had hidden that could be used for self-harm.

The mental health team offered funding for extra staff to help manage the risk.

In an email to the ward offering support, Ms Ellis said "so here we are again, another person waiting for a tier 4 bed".

She was asked by Coroner Darren Stewart if this was a recurring problem.

She replied it was a "significant problem" in her view, "especially since the pandemic".

The inquest continues.

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