‘Systemic failures’ contributed to teenager’s death

Longstanding issues with leadership and clinical oversight across two trusts contributed to failures surrounding the death of a teenager, two independent reviews have found.

Lucy Curtis, 17, died in hospital on 1 January 2024, five days after an incident of self-harm where she was found unresponsive at the Riverside Adolescent Unit at Blackberry Hill Hospital in Bristol.

The hospital is run by Avon and Wiltshire Mental Health Partnership Trust. Lucy had previously been admitted “informally” to Wessex House General Adolescent Unit, which is run by Somerset Foundation Trust, after her mental health deteriorated in summer 2023, and had been discharged on 27 November.

An inquest into her death finished on Friday. It found there were “multiple missed opportunities and failures” in Lucy’s care across both trusts, which “possibly” contributed to her death.

Its judgment was critical of poor communication around Lucy’s discharge from Wessex House, and a delay in accepting her onto the caseload of the AWP child and adolescent service. It also criticised Riverside’s failure to adequately observe her, and problems with delivering emergency treatment when she was discovered by staff.

In addition, an independent review published earlier this year, commissioned by the South West mental health provider collaborative and shared with HSJ, found “systemic failures across the care pathway”, which left Lucy “without timely, coordinated, and effective support at critical points”.

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Source: HSJ, 13 July 2026