Family Speak Of Heartbreak After 17-Year-Old Takes Her Own Life

The family of a teenager who took her life after she was transferred to a mental health hospital 170 miles from home have called for lessons to be learned following her death.

Mia Titheridge was found unresponsive in her room by staff at Huntercombe Hospital, near Norwich, in the early hours of 19 March, 2017. 

The 17-year-old, who had been known to mental health services since around the age of eight and who was deemed a high risk patient, was supposed to be on 15 minute observations. Staff had not checked on her for 57 minutes when she found, an inquest was told.

Mia was pronounced dead a few hours after arriving at Norfolk and Norwich Hospital.

Following Mia’s death her mum Tori, 44, of Alwoodley, Leeds, instructed specialist medical negligence lawyers at Irwin Mitchell to help investigate her care and support the family through the inquest process.

Mia’s family have now joined their legal team in calling for improvements to be made in the care young people with a mental health Illness receive.

It comes after an inquest concluded that Mia died as a result of suicide after failures by the hospital to respond to Mia’s threats to take her life and failures to carry out frequent observations on the night she was found fatally injured.

The hearing had also been told:

• Mia should have been under 15 minute observations, however, a number of these were missed between 8.30pm on 18 March, 2017 and 1.57am the following day when she was found unresponsive. The longest time period was 57 minutes between 12.59am on 19 March and 1.56am when staff discovered her.
• Mia brought a ligature and alcohol back to the hospital following a home visit the weekend before her death but staff did not find this in searches
• Huntercombe Hospital closed following Mia’s death and after the health watchdog the Care Quality Commission found it was failing to protect young people.

Coroner Jacqueline Lake said she was considering issuing a prevention of future deaths order regarding the case.

Expert Opinion

“This is an incredibly tragic case and sadly one of a growing number we are seeing where vulnerable young people with mental health difficulties have not received the care they deserve.

“For more than two years Tori and the rest of the family have held a number of concerns about the events that unfolded in the lead up to Mia’s death.

“While we are pleased that we have been able to provide Mia’s family with the answers they deserve, nothing will make up for the anguish and pain her family continue to face.

“Some of the evidence into the care Mia received heard during the inquest is extremely worrying. While this hospital may have closed it is now vital that all mental health providers take note of this inquest and where appropriate learn lessons from Mia’s death to improve patient care.

“We will continue to support Tori and the rest of the family at this incredibly difficult time to help them try and come to terms with what happened as best they can.” Tania Harrison - Partner

Find out more about Irwin Mitchell's expertise in handling medical negligence cases 

Mia’s mum Tori said after the hearing: “We were against Mia being moved because of the distance. She was going to be moved to a place where she would be isolated and alone, hundreds of miles from her family and friends who could offer her the support she needed.

“Mia was terrified when she was transferred. We just didn’t see how this would help with her rehabilitation.

“The last time I saw Mia she thanked me for a lovely weekend. Little did I know that would be the last time I saw my beautiful daughter.

“The only meaningful contact I had from Huntercombe Hospital was on the Monday following Mia’s home leave when they called to say she was drunk. At no point did they ever raise other concerns and there was never any indication that Mia had tried to harm herself.

“Mia was my world. She was the most beautiful daughter I could have wished for who had her entire future ahead of her. We remain absolutely devastated that she is longer here and will not get to fulfil her ambitions or celebrate milestones in life such as starting work or getting married.

“Listening to the evidence around why she died has been heart-breaking but what is even worse is that we are left with the feeling that Mia’s death could have been prevented. 

“It is difficult not to think that those who were supposed to provide the care she needed to make her better let her down when she needed help the most.

“Sending vulnerable people, particularly young people, hundreds of miles away from home to receive treatment does not work. We feel that more needs to be done to ensure their loved ones who can provide vital encouragement and support remain close by.

“While we know that nothing can ever bring Mia back we will continue to campaign for improvements in mental health provision as we would not wish the hurt and pain we are left to face every day on anyone else.”

Background

Mia had attempted to take her life several times before. She had been receiving treatment at a hospital in Sheffield and was regularly visited by her family.

However, in December 2016 she was moved to Huntercombe Hospital because she was deemed high-risk because of her repeated attempts of self-harm, Norfolk Coroner’s Court was told.

Tori objected to the proposal because Mia would be too far away from her family.

On 9 March Mia self-harmed but staff at Huntercombe Hospital deemed Mia could go return home to her family for a weekend visit.

The following day when Mia went home staff found a note in Mia’s room. Hospital staff phoned Tori to check on Mia during her home visit but did not mention in the call that they had found the note.

During the weekend Mia told her mum that she did not like the hospital, staff, the infrequency of visits by them and how staff had threatened to withdraw her home leave, the court was told. Tori reported these to the Huntercombe Hospital.

When Mia returned to the hospital on 12 March she was searched and a ligature and alcohol were missed. The following day staff had found her drunk in her room.

The following day a risk assessment indicated Mia remained at risk of self-harm.

In the early hours of 19 March Mia was found unresponsive in bed in her room. She died later that day of compression to the neck and a brain injury.

The Care Quality Commission inspected Huntercombe Hospital on 13 and 14 March, 2017 - days before Mia’s death – and again on 23 March, 2017. It rated the hospital as requiring improvement.

Huntercombe Hospital was closed following the publication of a follow up unannounced inspection report in February 2018 which ordered no new young patients be admitted because the CQC had found “significant and immediate concerns that required immediate action.”  

The hospital did not “protect young people from carrying out acts of self-harm and aggression. Young people “had access to dangerous items as weapons or for acts of self-harm” and the site “did not learn lessons from serious incidents or take effective action to reduce the risk that a similar event would happen again.”

The CQC also found staff “failed to report some incidents” in line with the care company’s policy and “managers did not review or investigate all serious incidents robustly, openly and transparently.”