Hospital slammed for failing teenager who took her own life
PUBLISHED: 10:24 29 November 2019
A hospital has been strongly criticised for its failure to adequately care for a teenager who took her own life while a patient on one of its wards.
Mia Titheridge, from Yorkshire, was an inpatient at the now closed Huntercombe Hospital in Buxton, near Aylsham, when she was found unresponsive in her room on March 19, 2017.
The 17-year-old was taken to the Norfolk and Norwich University Hospital but died the same day.
After seven days of evidence relating to the events leading up to and surrounding Miss Titheridge's death a jury found she took her own life following a failure from staff to respond to her low mood, risk of self-harm and suicidal thoughts.
The inquest heard there was also a failure to carry out observation checks on the night of March 18 and morning of March 19 2017.
During the course of the inquest, Norfolk Coroner's Court heard evidence Miss Titheridge had suffered from mental health problems from a young age and had a history of self harm.
In the fortnight leading up to her death, the court heard how Miss Titheridge had gone on home leave, but that her mother had not been told the teenager had recently self harmed.
She was also not informed a suspected suicide note was discovered in her hospital room while she was on leave.
The court heard how on the night of the 18/19 March 2017, when the teenager was supposed to be observed every 15 minutes, she went unchecked for 57 minutes between 12.59am and 1.56am.
And only 41 of the 72 observations which should have been completed were carried out.
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Olaoye Fagbemiro, the nurse who was supposed to be making the observations on Miss Titheridge's ward until 1.30am, last checked on her at 12.59am for four seconds.
Miss Titheridge was found unresponsive in her room by another member of staff at 1.56am.
Following the inquest a spokesperson for The Huntercombe Group expressed their condolences to the family and friends of Miss Titheridge, saying: "This inquest highlighted that one registered mental health nurse failed in their professional duty of care and did not carry out the observations of Mia they were required to do.
"As a result of this nurse's actions we (along with the Coroner) will be referring them again to the Nursing and Midwifery Council in the hope action will be taken against this individual.
"We also support the letters that the coroner will be issuing to Royal College of Psychiatrists and General Medical Council with regards to the actions of two individual clinicians."
The spokesperson said the group would also be conducting spot checks on CCTV on nightshifts to ensure staff observation duties are met.
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