A coroner has said Britain is failing young people and more will die due to under-resourced mental health services, ruling that negligence led to the death of a 14-year-old girl.
Penelope Schofield, West Sussex’s chief coroner, said she would write to health secretary Sajid Javid to express her concern after the case of Robyn Skilton, who committed suicide after being disappointed by “serious failures” in National Health Service mental health services.
Robyn, from Horsham in West Sussex, disappeared from her family home and took her own life in a park on May 7 last year, her Chichester inquest heard.
Despite serious concerns about her mental health, Robyn did not receive in-person consultations, was not seen by a child psychiatrist or assessed for mental health issues, and was discharged from an NHS service a month before her suicide. even though he was on their high-risk “red list.”
Her father, Alan Skilton, a director of a software company, told the inquest that he asked for help and described the lack of attention his daughter received as “astonishing”. He said that he believed that if Robyn had been seen sooner, her mental health would have improved and she would not have killed herself.
Skilton said that Robyn was outgoing, sociable and made friends easily, enjoyed ballet, gymnastics and swimming, and was “naturally artistic”. But she had mental health problems, repeatedly self-harmed, attempted suicide and was admitted to hospital four times. She told doctors that she heard voices and saw images.
The coroner said: “As a society we are failing young people.” He said he was surprised to hear that the number of young people seeking mental health help had increased by 95%. “Trying to manage it without more resources means that we are not providing the help that young people need. Robyn’s case is a testament to that. It is a clear risk that more lives will be lost if we don’t address it.”
Schofield ruled that there were serious failings on the part of the Sussex Partnership NHS foundation trust and its Child and Adolescent Mental Health Service (CAMHS).
She said: “I appreciate the landscape the trust was working on as Covid-19 increased the level of complexity, but there were a lot of flaws in the care provided to Robyn. The totality of these failures, in my opinion, means that I must come to a conclusion of abandonment. There was a serious lack of attention to a person in a state of dependency. Robyn took her own life while struggling with her mental health.”
Problems described by the coroner included CAMHS not evaluating Robyn “adequately or at all,” resulting in missed opportunities to address her growing needs for several years, but in particular in April 2021, when it was clear that his life was in danger.
Schofield said no face-to-face consultations were arranged or the Robyn CAMHS treatment offered. She ruled that the decision to discharge the teen from CAMHS and instead seek autism support was inappropriate.
Dr. Alison Wallis, clinical director of the Trust for Children’s Services, told Robyn’s parents, “They didn’t get the service they deserved.” She said that Covid had affected her care.
Rebecca Agnew, an attorney representing the trust, said: “CAMHS did not adequately assess Robyn, resulting in missed opportunities for her growing needs…The trust extends a formal apology to her parents for these failures.”
A spokesperson for the Sussex Partnership NHS foundation said: “We offer our deepest condolences to the family and friends of Robyn Skilton and apologize unreservedly that our care and support failed to recognize her vulnerability and provided the intervention and help that we needed.” needed.
“In response, we have made significant changes to the way we monitor and escalate cases where there is an increased risk. Working with our partners, we have also introduced a new referral system and are developing a new direct service to provide access to specialized well-being and emotional support for children and young people.”
