Vital opportunity missed for early intervention that could have prevented Great Cornard teenager’s death, report finds

The death of a Suffolk teenager could have been avoided according to a new coroner’s report, which says a vital opportunity for early intervention was missed.

Suffolk area coroner Darren Stewart warned that there is a risk of future deaths unless lessons are learned from the case of Great Cornard schoolgirl Erin Tillsley, who died last year.

An inquest in May found that the 14-year-old – described by her family as a ‘bubbly, bright and loving young person’ – had taken her own life in July 2023.

This followed several months of struggles with her school attendance – during which time she had been admitted to West Suffolk Hospital in December 2022, after overdosing on prescription medication.

The coroner’s latest report has now concluded that clinical guidance, for managing and preventing recurrence of self-harm, was not followed during this admission.

He indicated that, because of this, clinicians missed an important opportunity, where mental health services could have engaged with Erin earlier than they eventually did.

Mr Stewart said: “During the course of the investigation, my inquiries revealed matters giving rise to concern.

“In my opinion, there is a risk that future deaths could occur, unless action is taken.”

The coroner called on the West Suffolk NHS Foundation Trust (WSFT) and the Suffolk and North East Essex (SNEE) Integrated Care Board (ICB) to develop an action plan to address these concerns.

At the end of the inquest in May, Suffolk area coroner Darren Stewart said: “Erin Tillsley was described by her family as a bubbly, bright and loving young person, who exuded warmth and charisma.

“She was a person whose company was uplifting, and who had a desire to see the lives of those around her enhanced.”

The inquest heard that Erin was admitted to West Suffolk Hospital for an overdose on December 31, 2022.

She was assessed for her physical symptoms, which were not considered serious, and subsequently discharged on January 1, 2023.

The visit proceeded without a referral to psychiatric liaison services, the inquest was told, because emergency department staff did not consider this appropriate at the time.

However, advice was given for a referral by Erin’s GP to the Norfolk and Suffolk NHS Foundation Trust Wellbeing Hub, on January 4, 2023.

The referral was assessed by the Child, Family and Young Peoples (CFYP) mental health team, who then contacted Erin in May 2023.

However, the inquest’s conclusion stated it was not possible to determine whether she had been referred to counselling services.

It was also heard that, at the time of her death on July 14, 2023, no further contact with mental health services had occurred.

Evidence given during the inquest led the coroner to investigate the care during Erin’s initial hospital admission.

National Institute for Health and Care Excellence (NICE) guidance states patients who have self-harmed should have a full mental health and social needs assessment, with ‘evaluation of the social, psychological and motivational factors specific to the act of self-harm’.

In addition, the joint SNEE and Suffolk County Council (SCC) policy on young people in crisis outlines the resources available to assess and support mental health needs, as they arise, in an emergency department.

Mr Stewart said: “Evidence received during the inquest indicated that neither the NICE guidance, nor the SNEE/SCC policy, were applied, in relation to the care and treatment extended to Erin.

“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.”

WSFT and the SNEE ICB are now required to respond to the report by January 7, 2025.

In this response, they must set out a plan of action to address these concerns and a timetable for its implementation.

After the inquest closed earlier this year, WSFT chief executive Dr Ewen Cameron said: “Every patient deserves the highest quality and safest care.

“We have rightly carried out a patient safety review regarding Erin’s care with us.”

A trust spokesman added that they had received the report, and would continue to review its processes for children and young people in crisis.

This includes training and education for staff, on protocols for engaging with the trust’s mental health liaison team.