Girl, 12, killed herself after medical staff failed to spot brain disorder, inquest finds

A 12-year-old girl who took her own life after being sectioned was failed by medical staff who did not spot her underlying brain disorder, an inquest has found.

Mia Lucas was found unresponsive in her room at the Becton Centre, which is part of Sheffield children’s hospital, on 29 January last year.

Jurors heard that Mia had undiagnosed autoimmune encephalitis – a rare condition that causes swelling of the brain and which explained her “acute psychosis”.

The diagnosis only emerged partway through the inquest in Sheffield, after a pathologist said she had just received new port-mortem examination test results.

On Thursday, the inquest jury concluded that the failure to carry out a lumbar puncture at Nottingham’s Queen’s medical centre (QMC) before her transfer to the Becton Centre had “possibly contributed” to her death.

The inquest was told that Mia began behaving unusually over Christmas 2023, including hearing voices and attacking her mother. Her family became so concerned that she was taken by ambulance to QMC on New Year’s Eve.

She was found to be experiencing an “acute psychotic episode” and was sectioned under the Mental Health Act.

A jury of five women and four men heard that blood tests and an MRI scan conducted at QMC were negative, leading doctors to rule out a physical cause for her psychosis.

However, clinicians decided not to request further tests of brain activity or spinal fluid, including a lumbar puncture, which may have revealed the autoimmune encephalitis.

Mia was transferred to the Becton Centre on 9 January and died three weeks later.

In their narrative conclusion, the jury said: “The failure to undertake a lumbar puncture at this point [at QMC] meant that potential indicators of autoimmune encephalitis were missed. This possibly contributed to Mia’s death.”

They added that the information passed between QMC and the Becton Centre “provided an inappropriate level of assurance that organic causes had been ruled out”.

Regarding the Becton Centre, the jury found that “insufficiently robust communication and management of risk led to a failure to respond adequately to Mia’s risk of self-harm”.

The jury also noted that a “rare presentation of a rare condition” posed particularly complex challenges for diagnosis and care.

The jurors found, on the directions of the senior coroner for South Yorkshire (West), Tanyka Rawden, that Mia’s cause of death was compression of the neck, caused by acute psychosis, caused by autoimmune encephalitis.

In a statement after the inquest, Mia’s mother, Chloe Hayes, said: “It has been devastating to listen to how, when she needed specialist healthcare for the first time in her life, she was so badly let down.

“She was let down at the Queen’s medical centre in Nottingham, who wrongly decided there was no underlying physical cause of her psychosis, and failed to carry out appropriate testing.

“I believe they simply dismissed her and looked to pass her on to mental health services as quickly as possible, which led to her transfer to the Becton Centre.”

Mrs Hayes continued: “Her mental health spiralled deeper out of control there, as she was not being treated for her condition, and the many failings and lack of care meant sadly she wasn’t properly protected from harming herself.”

She said: “My beautiful little girl has lost her life and I will never forgive the Queen’s medical centre or the Becton Centre for failing her.”

Dr Manjeet Shehmar, the medical director at Nottingham university hospitals NHS trust, said: “We accept the coroner’s outcome in court today and apologise to Mia’s family for not identifying autoimmune encephalitis while she was in our care.

“While this is an incredibly rare condition and initial tests were negative, we recognise that further testing may have had an impact on her future, for which we are truly sorry.”

• In the UK and Ireland, Samaritans can be contacted on freephone 116 123, or email [email protected] or [email protected]. In the US, you can call or text the National Suicide Prevention Lifeline on 988, chat on 988lifeline.org, or text HOME to 741741 to connect with a crisis counselor. In Australia, the crisis support service Lifeline is 13 11 14. Other international helplines can be found at befrienders.org