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Mother responds to Serious Case Review into her daughter’s death at eating disorder clinic

Mother of teenager who hanged herself at a eating disorder clinic expresses disappointment with serious case review

27 February 2015

The mother of a 17 year old girl who hung herself whilst being treated in an eating disorder clinic has said she feels let down by The Hertfordshire Safeguarding Children Board following a serious case review which she claims fails to protect the lives of vulnerable young people.

Michaela Christoforou died on 17 April 2013 after hanging herself at Rhodes Farm, a clinic in Hertfordshire specialising in treatment of eating disorders where she was an inpatient.

Michaela was known to be at high risk of suicide at the time of her death and had made multiple previous attempts at taking her own life. An Inquest into Michaela’s death in May 2014 made a recommendation for ligature cutters to be made more widely available at the clinic to prevent future deaths occurring.

As Michaela was detained under the Mental Health Act at the time of her death, the law requires a formal Serious Case Review (SCR) to be undertaken into the involvement of state services in her life in the period leading to her death. The Hertfordshire Safeguarding Children Board (HSCB) has now published its SCR into the circumstances of Michaela’s death.

The SCR lists seven “learning points” identified by the Safeguarding Board.

These points include recommendations for improved co-ordination and information sharing between different agencies involved in the care of young people suffering from mental health difficulties in Hertfordshire.

Michaela’s mother, Carolyn Carpenter, has expressed her disappointment that the SCR found the levels of supervision of Michaela were appropriate, as she believes signs that should have led to ongoing increased supervision of Michaela were ignored.

Mrs Carpenter said she was also disappointed that the report did not identify any specific recommendations about the need for potential ligatures and ligature points to be properly risk assessed in institutions caring for young people known to be at high risk of suicide.

Mrs Carpenter said: “My daughter was suffering from extreme mental illness at the time of her death. She was in the care of professionals at the time whom we feel should have been aware of the risk of her taking her own life and have taken appropriate precautions to protect her.

“I feel let down that the HSCB report does not make recommendations which I believe could protect the lives of other young people.”

Mrs Carpenter also claims the report contains factual inaccuracies about the circumstances of her daughter’s death which she feels have not been fully understood or investigated by the HSCB.

The HSCB Review Report was published on the same day as the Equality and Human Rights Commission published the results of its inquiry into the civil liberties of patients detained in psychiatric institutions, which concluded that between 2010-2013 over 600 deaths occurred in psychiatric institutions which could have been avoided.

The Commission concluded that in many cases “basic mistakes” had led to deaths occurring, such as failing to properly monitor patients at serious risk of taking their own lives, or to remove ligature points commonly used to attempt suicide.

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