Prevention of Future Deaths report – Mary Bush (20 October 2021)

Summary

15 year-old Mary Bush had a diagnosis of anxiety disorder, post-traumatic stress syndrome and suicidal ideation, and on 6 August 2020, Mary took her own life.

In her report, the Coroner raises a number of concerns and highlights action that needs to be taken to prevent future deaths.

Content

In this report, the Coroner highlights the following concerns:

1. Mary was referred to the mental health team in November 2019 and was assessed in January 2020, some three weeks later than should have been.
2. There was a delay in Mary receiving psychological therapy. She was still on the waiting list at the time of her death.
3. The evidence was that at the date of inquest, there continued to be a delay in service users receiving psychological therapy. Evidence was heard that balancing capacity and demand, which has increased, remains a challenge. The cases referred are of increasing complexity, as in Mary’s case.
4. Some steps have been taken in an effort to deal with this, such as specific risk assessment training, focusing on intervention treatment plans to aid capacity and throughput, reviewing the skill mix of staff.
5. However, there is the ongoing issue of recruitment and retention of suitably skilled staff by the Trust and the ability to resource this to enable the Trust to function effectively.

This report was sent to NHS Norfolk & Waveney Clinical Commissioning Group, the Secretary of State for Health & Social Care, the Child Death Overview Panel and the Local Safeguarding Board.