Coroner demands urgent changes at NHS trust over mental health care

Coroner demands urgent changes at NHS trust over failings in its mental health care after inquest ruled girl, 14, killed herself after claiming that she was sexually abused from age of seven

  • Maziellie Mackenzie, 14, took her life following a series of failings by NHS trusts
  • 在六月 2018, she went missing while on playground trip under care of The Cove
  • Less than four hours after she disappeared, her body was found in woodland
  • Coroner has sent Prevention of Future deaths report to trust involved in her care
  • Anyone seeking help can call Samaritans free on 116 123 或访问 Samaritans.org
  • A coroner has demanded urgent changes at an NHS trust over failings in its mental health care after an inquest ruled a teenage girl killed herself after claiming that she was sexually abused from the age of seven.

    Maziellie Mackenzie, known as Mazie, took her own life aged 14 following a series of failings by NHS trusts involved in her care.

    Social services became involved in Mazie’s life a month before her first birthday when she and her mother, Wendy, were found to be living in a car in Cumbria.

    在六月 2018, she went missing while on a trip to a playground in Heysham under the care of The Cove, which is run by Lancashire and South Cumbria NHS Foundation Trust (LSCFT).

    Less than four hours after she disappeared, her body was found in a secluded woodland area and she was pronounced dead at the scene.

    去年十月, Assistant Coroner Phil Holden concluded that Mazie’s death was suicide and revealed his intention to hold a further hearing, to find out what changes had been made at the NHS trust.

    The coroner has now sent as a Prevention of Future Deaths report to LSCFT, giving them 56 days to formally notify him of steps taken to improve services at The Cove, saying that future deaths will otherwise be likely.

    Maziellie Mackenzie (上图), known as Mazie, took her own life aged 14 following a series of failings by NHS trusts involved in her care

    Maziellie Mackenzie (上图), known as Mazie, took her own life aged 14 following a series of failings by NHS trusts involved in her care

    After repeated and regular instances of going missing, Mazie said that she was being sexually exploited by drug dealers in order to pay off cannabis debts.

    Mazie also claimed she had been sexually abused by numerous men from the age of seven, but her mother refused to believe her and called her a liar.

    在五月 2018, 老化的 14, Mazie moved to a specialist residential care home for victims of child sexual exploitation in Yorkshire. She quickly settled in and became good friends with a resident.

    Staff at the home developed a close bond with Mazie. But Mazie was unable to escape her past and the alleged abuse she had suffered at the hands of those she should have been able to trust. She told staff at the home how she had been sexually exploited when she was younger.

    The allegations were formally reported to Cumbria Police. But nobody was ever arrested in connection with the 11 investigations which were ongoing at the time of Mazie’s death.

    在他的信中, which has also been sent to Mazie’s family, Mr Holden said: ‘During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken.

    ‘In the circumstances it is my statutory duty to report to you.

    ‘The matters of concern are as follows; Expert evidence was heard (and accepted) at inquest that there was no written policy/document in place by the Trust which set out the circumstances in which group leave from the Cove ( and other tier 4 单位) is granted and who is responsible for the granting of such leave, that a mandatory risk assessment is required and setting out a list of factors/criteria that must be considered before any group leave is granted, setting out the staff to patient ratios for any group leave and identifying the criteria to be considered.

    在声明中, LSCFT said: ‘We would once again like to reiterate our deepest sympathies to Mazie’s family and friends. We appreciate that any inquest is difficult for the loved ones involved, and particularly so when the death is that of a young person.

    ‘Since this tragic event in 2018, we have used the learning from our investigation to make improvements in the unit, 例如, how we manage escorted leave. The safety of our service users is our top priority, and we are committed to continually improving.

    Around the age of one, Mazie was placed in temporary care for a month and, upon returning to her childhood home in Barrow-in-Furness, the authorities had no alternative but to step in on numerous occasions amid fears for her safety.

    When she was just five Mazie told a social worker that her mother was using drugs.

    When Mazie was eight, social services flagged up concerns about her mum’s drinking and use of drugs and three years later.

    在九月 2014, Wendy was arrested on suspicion of child neglect. At this time Wendy was seeing a man called Garya relationship marred by a ‘significant pattern of alcohol consumption’, arguments, and their ‘lack of understanding about how it affected Mazie’.

    通过 2016, when Mazie was 13, social services acknowledged that the time had come to take their intervention to the next stage and through the family court obtained an interim child protection order; and later a full care order, to retain custody of Mazie, a process which mum Wendy did not oppose.

    From then on Mazie became what is known as a ‘looked-after child’.

    After repeated and regular instances of going missing, Mazie (图为) said that she was being sexually exploited by drug dealers in order to pay off cannabis debts

    After repeated and regular instances of going missing, Mazie (图为) said that she was being sexually exploited by drug dealers in order to pay off cannabis debts

    五月之间 2016 和七月 2017 Mazie was placed with three different foster families in Barrow and Dalton but each placement eventually broke down because of her complex emotional needs and behaviour.

    She spent eight months in a children’s home in Barrow, between July 2017 和三月 2018, during which time it became apparent that Mazie was in urgent need of more intensive support.

    By the middle of 2018 Mazie’s self-harming had escalated. Staff at the home in Yorkshire no longer felt they could keep her safe.

    在5月 14, Mazie was left distraught after speaking to her mother on the phone and hearing the voice of one of her former partners in the background.

    ‘She couldn’t believe her mum had got back with him’, 审讯听到.

    第二天, as a result of her distress at discovering her mother was back with her ex, Mazie was taken to York Hospital in May 2018 but doctors failed to follow policy and did not undertake a full mental health assessment or refer Mazie to the Child and Adolescent Mental Health Services.

    It was then recognised that Mazie needed to be placed in what is known as a Tier 4 unitan in-patient setting for young people with complex mental health needs, but the various hospital trusts which had been involved in her care couldn’t agree which of them should fill in the form to refer her to such a place.

    Mazie was originally from Cumbria but when admitted to York Hospital had come under the care of York and Scarborough Teaching Hospitals NHS Foundation Trust and, 后来, that of Mid Yorkshire Hospitals NHS Trust when she was admitted to Pinderfields Hospital in Wakefield.

    This disagreement led to Mazie being left in limbo, in a children’s ward at a hospital in Wakefield, for three weeks.

    Eventually the clinical director of Cumbria’s Child and Adolescent Mental Health Services, Barry Chase, decided enough was enough and, disregarding protocol, put his name to a referral which would allow Mazie to move to The Cove in Heysham.

    Three weeks after moving to Heysham, Mazie went on a trip to a nearby playground, 在六月 23 在 2018, along with three other girls and two members of staff.

    When the girls refused to return to The Cove and ran away from the two healthcare assistants Mazie also went missing.

    Within the space of around 20 minutes the other girls were found, and agreed to return to The Cove, but Mazie was nowhere to be seen.

    The last sighting of her was at around 7pm when a nurse from The Cove spotted Mazie on the bypass while on her way into work.

    Mistakes in how Mazie’s disappearance was logged by Lancashire Police meant that it was almost two hours before officers began searching for her.

    At just after 10pm, less than four hours after Mazie had disappeared, a group of teenagers came across her body in a secluded woodland area.

    Despite the efforts of police officers who were first on the scene and tried to resuscitate her, Mazie was pronounced dead at 11.03pm.

    At the conclusion of the inquest, the trust said in a statement: ‘We would like to reiterate our deepest sympathies to Mazie’s family and friends.

    ‘We appreciate that any inquest is difficult for the loved ones involved, and particularly so when the death is that of a young person.

    ‘Since this tragic event in 2018, we have used the learning from our investigation to make improvements in the unit, 例如, how we manage escorted leave. The safety of our service users is our top priority, and we are committed to continually improving.

    MailOnline has reached out to the trust for further comment.

    Anyone seeking help can call Samaritans free on 116 123 或访问 Samaritans.org

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