Madeleine Savory inquest: Staff did not check teen's self-harm history

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

Hospital staff caring for a 15-year-old who died after an attempt on their own life were too busy to fully check the patient's records, an inquest heard.

Madeleine Savory died at Ipswich Hospital in February 2022.

While waiting for a bed, Madeleine made an attempt on their life on 19 February and died a week later

Consultant paediatrician Dr Mariette Fernando told the coroner's court that staff were not fully aware of the patient's specific risks of self-harm.

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, the inquest in Ipswich heard.

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

They were on a ward while waiting for another bed to become available.

'Making assumptions'

Dr Fernando said doctors on the ward did not routinely go through admitted patients medical records due to time constraints, which meant ward staff were not aware of potential heightened risks.

She said she "would have hoped that the mental health team would have alerted us to those factors", but she added that "both sides were making assumptions of the other side".

Dr Fernando said time pressures were still present, but extra staff now went through records and informed doctors.

The inquest continues.

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