NHS Trust failed schoolgirl, 14, who was found hanging a month after she was discharged from mental health programme, inquest hears
An NHS Trust today admitted failings in the tragic case of a 14 year old schoolgirl who took her own life a month after being discharged from its children’s mental health programme.
Robyn Skilton began self-harming and suffering low moods after she joined secondary school, worrying that ‘nobody liked her’.
The teenager’s parents, Alan and Victoria, sought help from Sussex Child and Adolescent Mental Health Services [CAMHS].
But in the two and a half years that followed, Robyn, from Horsham in West Sussex, was not given any proper assessments or treatment despite her mental health plummeting, her inquest heard today.
Despite being admitted to hospital for self-harm and suicide attempts, heartbroken software company director Mr Skilton said he was ‘astonished’ at the lack of support she received.
Robyn Skilton, pictured, from Horsham, West Sussex, had a long history of self harming according to her inquest
The inquest heard Robyn had told her parents that she had threatened to jump from a bridge to her death
Tearful Mr Skilton – who said he and his wife ‘tried everything we could to help’ their daughter – said CAMHS did not intervene and accused the NHS of following a ‘tick-box exercise’ to get her discharged from hospital.
At one point the teenager even threatened to jump off a bridge, but her parents’ fears were dismissed, the inquest heard.
Today at West Sussex Coroner’s Court in Chichester, Mr Skilton said: ‘We know that we can’t bring her back but we do think if she had been put through treatment she would be here with us.’
Robyn was discharged from CAMHS on April 9, 2021, ‘but had not really provided support at all’.
Less than a month later, on May 7, Robyn was found hanged in Horsham’s Southwater Country Park having disappeared from the £670,000 family home.
She regularly self-harmed and expressed suicidal ideations – and even told her parents ‘nobody could help her’, the inquest was told.
Solicitor Rebecca Agnew, from Sussex Partnership NHS Foundation Trust, today told Robyn’s family: ‘The Trust seeks to formally acknowledge the failings in Robyn’s care and the impact on her family.
‘CAMHS didn’t assess Robyn appropriately, leading to missed opportunities to her needs.
‘The Trust is aware that it didn’t communicate with Robyn directly and it did not contact the family directly.
‘The Trust extends a formal apology to her parents for these failings.
‘The Trust did not adequately assess Robyn and provide her with the care and assistance she needed and this more than minimally, trivially or negligently contributed to Robyn’s death.’
Mr Skilton told the hearing: ‘We do believe if Robyn had been seen properly earlier… her mental health would have improved and she would not have committed suicide.’
Robyn’s father said his daughter was ‘outgoing, social, and made friends easily’, and that she enjoyed swimming, singing and dancing.
Mr Skilton said Robyn’s troubles began after she moved to all-girls Mallais School in Horsham in 2017.
He said: ‘Her friendship group had changed… She was struggling to bond with others.
‘We started to notice problems with her mood, she started to feel sad and self-harm and she didn’t know why she did it.
‘She thought that nobody liked her.’
West Sussex Coroner’s Court, sitting in Chichester, pictured, heard that after changing school, Robyn’s family noted ‘problems with her mood. Her father said: ‘She thought nobody liked her’
Mr Skilton said he contacted CAMHS but ‘we never imagined that two and a half years would pass and Robyn would take her own life without anyone really intervening’.
Mr Skilton said it was ‘shocking’ that CAMHS did not speak with him and his wife after they once took Robyn to hospital when they believed she would take her own life.
He said: ‘We question why [CAMHS think] a child who wanted to take her life has the capacity to fill out a self-questionnaire.’
By Christmas 2020, her parents were ‘extremely worried’ about her mental state and Robyn ‘was saying nobody could help her’.
‘She was aware what she was doing was dangerous’, Mr Skilton said. ‘She said she could not see a future.’
Mr and Mrs Skilton hid sharp objects but Robyn found them and continued to self-harm.
In early 2021 it was heard she was admitted to hospital. She tried to overdose on paracetamol and stayed three nights, however Mr Skilton was shocked by her lack of treatment.
He said: ‘We were astonished that after she attempted to take her own life she left hospital with less support.
‘Nobody seemed to take her mental health seriously.’
Robyn ‘clearly got worse’ in 2021 however on April 9 CAMHS discharged her.
Mr Skilton said: ‘CAMHS sent her a letter discharging her but they had not really provided support at all.
‘In the last few weeks of her life she was verbally abusive and self-harming on a regular basis.
‘It’s deeply painful to learn that Robyn told professionals at the hospital that she was hearing voices… We don’t understand why this was not shared with us.’
Robyn’s parents became ‘desperate’ and sought private care through the Priory – which would charge £1,300 a night.
‘We told CAMHS that we don’t think we can keep her safe and asked if she could be sectioned’, Mr Skilton said.
Mr Skilton added: ‘To our surprise, her mood changed completely, she said she was sorry for how she had been.
‘Because she engaged with us that night it gave us false hope… and we didn’t get the professional help but I wish we did.’
It was heard she was admitted to hospital four times.
‘The hospital just seemed to go through a tick-box exercise trying to get her discharged’, Mr Skilton claimed.
‘Even when she threatened to jump off a bridge our pleas for help were dismissed.’
Sussex Child and Adolescent Mental Health Services [CAMHS] initially declined a referral for Robyn to its programme, the tragic teenager’s GP today told her inquest.
Dr Matthew Davies, of Riverside Medical Centre in Horsham, said CAMHS declined his referral as they were ‘unsure’ if her condition was ‘moderate or severe’.
The 14 year old was eventually taken on the CAMHS programme but discharged a month before being found dead.
Dr Davies said Robyn and her parents first visited him in 2018.
He said he referred her to the Youth Emotional Support [YES] – a West Sussex County Council service which provides free wellbeing support to 11 to 18 year olds.
However, the family argue that it was their understanding that they were seeking a CAMHS referral.
There was confusion over whether Robyn was due to receive support from YES in school, it was also heard.
Cases are escalated to CAMHS when they are serious, the inquest heard. YES receive 2,500 referrals each year and two per cent are sent on to CAMHS.
Group therapy was not considered suitable for Robyn, the inquest heard.
The two day inquest continues.
- For confidential support, call the Samaritans on 116123 or visit local Samaritans.