A 12-year-old girl who died after an incident of self-harm was failed on multiple levels, an inquest jury has found.
Warning: This story contains references to self-harm and suicide
Mia Lucas, who died in January 2024, was found unresponsive at an NHS children’s psychiatric unit after developing a rare neurological disorder that had been left undiagnosed.
The jury at Sheffield Coroner’s Court heard the girl was found at the Becton Centre, part of Sheffield Children’s NHS Foundation Trust.
She had been placed there after being sectioned while suffering an “acute psychotic episode” during an assessment at the Queen’s Medical Centre (QMC) in Nottingham.
On Thursday, the jury found that the failure to undertake a lumbar puncture at QMC before her transfer to the Becton Centre “possibly contributed to Mia’s death”.
A lumbar puncture involves a needle being inserted into your lower back to find out if symptoms are caused by a brain or spine condition.
The jury also said there was a failure at the Becton Centre to respond adequately to Mia’s risk of self-harm.
Professor Marta Cohen told the jury Mia’s cause of death was “compression of the neck” but she had now added that this was caused by “acute psychosis”, which was caused by “autoimmune encephalitis”, an inflammation of the brain that can cause extreme psychiatric symptoms and is treatable.
The autoimmune encephalitis diagnosis emerged during the nine-day inquest after a pathologist revealed she had received new post-mortem results.
The revelation prompted shock in the courtroom and tears from Mia’s family members in the public gallery.
The condition was described as “complex and rare”, according to consultant paediatric neurologist Mike Taylor.
He added that there was a low level of suspicion Mia had it, while being assessed at QMC, and told the court that experts had to consider the very severe treatment side effects, which included death.
Mia’s mother, Chloe Hayes, told Sky News she was unhappy at how the Beckon Centre had supervised her daughter.
“All they had to do was watch her. I actually never got told the truth about the attempts that Mia made [to self-harm] until after she died,” she said.
“If I’d have known the truth I wouldn’t have left Mia there. And I think she had so much to live for. I don’t think she knew what she was doing.”
Anyone feeling emotionally distressed or suicidal can call Samaritans for help on 116 123 or email [email protected] in the UK. Alternatively, you can call Mind’s support line on 0300 102 1234, or NHS on 111.
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