A senior coroner has said we are “failing” our young people after a teenage girl was denied face-to-face appointments before she killed herself during lockdown.
Penelope Schofield warned there is a “clear risk” young people will succumb to mental illness if urgent action is not taken as she announced she was writing to Sajid Javid, the Health Secretary.
The coroner concluded that Robyn Skilton, 14, killed herself after being let down by “gross failures” in the NHS.
The failures were so severe in the case of the suicidal teenager – who was continually turned down for assessments – that Ms Schofield ruled the NHS was guilty of “neglect”.
Robyn, from Horsham in West Sussex, disappeared from her £670,000 family home and hung herself in a park on May 7 last year, having a long history of self-harming and expressing a desire to take her own life.
At that time, England was in step two of the Government’s route map out of lockdown and no indoor mixing between different households was allowed.
Despite “real serious concerns” about her mental health, Robyn did not get face-to-face 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 despite being on its high-risk “red-list”.
She was referred to a council support program but was kept on a waiting list for a one-to-one consultation for ten months.
Eventually, when she had a consultation, it was only a remote session because of the pandemic.
Robyn’s father Alan Skilton, a software company director, constantly pleaded with authorities for help.
‘Astonishing’ lack of care
He told his daughter’s inquest the lack of care she received was ‘astonishing’.
Ms Schofield, who has presided over a number of high-profile inquiries including the Shoreham Airshow disaster, announced she would be writing a report to the Government following the hearing.
“As a society, we are failing young people,” Ms Schofield warned.
Ms Schofield said she was ‘shocked’ to hear evidence during the two-day-long hearing that the number of young people seeking mental health help has increased 95 per cent in recent times.
She said: “Trying to manage it without more resources means we are not providing the help that young people need.
“Robyn’s case is a testament to that.
“It’s a clear risk that more lives will be lost if we don’t address it.
“Therefore, I will be writing a Prevention of Future Deaths report to the Secretary of State for Health to address these concerns.”
Ms Schofield added that young people ‘need resources to get them the help they need’.
Ms Schofield ruled there were ‘gross failures’ by Sussex Partnership NHS Foundation Trust in Robyn’s case and the Trust’s Sussex Child and Adolescent Mental Health Service [CAMHS].
‘I must reach a conclusion of neglect’
She said: “I do appreciate the landscape the Trust was working in as Covid-19 heightened the level of complexity, but there were many failings in the care provided to Robyn.
“The totality of these failures, in my mind, means I must reach a conclusion of neglect. There was a gross failure to provide care for someone in a dependent state.
“Robyn took her own life while struggling with her mental health.
“Mental health services failed Robyn as they didn’t recognize the deterioration of her mental health, nor provide her with the care she required.
“Her death was also contributed to by neglect.”
Dr Alison Wallis, the Trust’s clinical director for children’s services, tearfully told Robyn’s parents ‘you didn’t get the service you deserved’ and that Covid impacted their care.
Ms Schofield outlined the key failings.
‘We tried everything we could to help’
These included failure by CAMHS to assess her “appropriately or at all”, leading to missed opportunities to address her “escalating needs” over several years but “in particular April 2021 when it was clear there was a risk to life”.
Ms Schofield said there was a failure to arrange face-to-face consultations, a lack of direct communication, a failure to offer her CAMHS treatment when she met its criteria, and a failure “to have Robyn assessed at any time.”
She ruled the “decision to discharge her from CAMHS and instead pursue autism treatment was inappropriate” and that Robyn should have seen a child psychiatrist.
Robyn’s father, who attended the inquest in Chichester with his wife and Robyn’s mother, Victoria, said “we tried everything we could to help” the teenager.
He said: “We do believe if Robyn had been seen properly earlier… her mental health would have improved and she would not have committed suicide.”
Robyn was “outgoing, sociable and made friends easily”, enjoyed ballet, gymnastics and swimming, and was “naturally artistic” and loved singing and dancing.
However, her troubles began in late 2018, after she moved to all-girls Mallais School in Horsham the year before.
Robyn suffered mental health breakdowns, repeatedly self-harmed, attempted suicide, and was admitted to hospital four times, later telling medics she was hearing voices and seeing images.
She was referred to West Sussex County Council’s Youth Emotional Support Service and attended group sessions but they did not provide her support and was kept on a waiting list for a one-to-one consultation for 10 months.
Eventually, when she had a consultation, it was not effective as it was remote due to the pandemic.
CAMHS would not initially take her on even though she met its criteria, and when the service did, it focused on trying to assess her for autism.
Her parents were told self-harming was a “coping mechanism”, Robyn didn’t get bi-weekly check-up calls, and she was not spoken to directly by CAMHS.
Mr Skilton was left “shocked” Robyn was given a self-questionnaire to fill out when she was suicidal and was left repeatedly frustrated at not being kept in the dark by authorities due to “confidentiality”.
‘Our pleas for help were dismissed’
“The hospital just seemed to go through a tick-box exercise trying to get her discharged”, Mr Skilton claimed. “Even when she threatened to jump off a bridge our pleas for help were dismissed.”
Robyn said ‘nobody could help her’ and that she was ‘looking forward to ending her life’.
In early 2021 she was rushed to hospital for trying to overdose on paracetamol and stayed three nights. Mr Skilton said: “We were astonished that after she attempted to take her own life from her she left hospital with less support.
“Nobody seemed to take her mental health seriously.”
Mr and Mrs Skilton became “desperate” at the lack of help Robyn received near her death, asked CAMHS if she could be sectioned, and considered having her admitted to the Priory, at £1,300 per night.
Mr Skilton said in the days before her death “her mood changed completely” and it gave her parents “false hope”.
Solicitor Rebecca Agnew, from Sussex Partnership NHS Foundation Trust, admitted “CAMHS didn’t assess Robyn appropriately, leading to missed opportunities for her escalating needs”.
She added: “The Trust extends a formal apology to her parents for these failings.
“The Trust did not adequately assess Robyn and provide her with the care and assistance she needed and this more than minimally, trivially or negligently contributed to Robyn’s death.”
Giving evidence, CAMHS senior practitioner Carly Mendy admitted: “It was inappropriate to discharge her from the service.”
CAMHS clinical specialist, Velani Bhebhe admitted their risk assessment of Robyn was “not detailed enough”.
Sussex NHS Trust has started implementing large changes to its mental health services and Ms Schofield will reconvene the inquiry in three months to assess them.