‘Systemic failures' led to unlawful death of girl at mental health unit

Independent

2 days ago

The parents of a teenage girl who died after being left alone at a children's mental health ward by an agency worker using a fake ID have said 'systemic failures' led to her unlawful death.
Ruth Szymankiewicz was being treated for an eating disorder at Huntercombe Hospital in Berkshire and had been placed under strict one-to-one observation when on February 12 2022, she was left on her own by the member of staff responsible for watching her.
The 14-year-old was able to shut herself in her bedroom at the hospital's psychiatric intensive care unit – also known as Thames ward – where she self-harmed.
She died two days later at John Radcliffe Hospital in Oxford.
On Thursday, an inquest jury sitting at Buckinghamshire Coroner's Court in Beaconsfield returned a conclusion of unlawful killing.
Speaking outside the court after the hearing, Mark and Kate Szymankiewicz said: 'When, at our most vulnerable as a family, we reached out for help; we ultimately found ourselves trapped in a system that was meant to care for her, to help her, to keep her safe, but instead locked her away and harmed her.
'Having been detained in a unit she should never have been sent to, Ruth was repeatedly denied access to the love and support of her family.
'We were excluded and completely disempowered. She was isolated, scared and alone.'
Mark, a consultant surgeon, and Kate, a GP, added: 'Over the last two weeks, we have heard about the numerous systemic failures at Huntercombe Hospital.
'Ruth was our daughter. But she could just as easily be your child, your niece or nephew, your grandchild.
'We hope that by sharing her story it can help inform the change needed in children's mental health services.'
During the conclusion hearing on Thursday, the jury foreman told the court: 'Ruth was not prevented from accessing the restricted material which could be used to self-harm.'
'Ruth was not prevented from accessing harmful material on the internet.
'Ruth's care pathway… was insufficient to allow improvement for discharge.
'From Ruth's admission to Thames ward, her responsible clinician deemed the ward to be neither suitable nor conducive to her recovery.
'Ruth's parents were not given adequate information about the appeal process, and refusal rights.'
Jurors could be seen crying as they recorded their conclusion, as well as the coroner and members of the family.
The agency worker responsible for watching Ruth – a man then known as Ebo Acheampong – had never worked in a psychiatric hospital environment before coming to Huntercombe on February 12 2022 for his first shift.
A police investigation later found he was hired by the Platinum agency – which supplied staff for Huntercombe Hospital – under a false name.
Mr Acheampong never returned to work at the hospital following the incident and fled the UK for Ghana.
The court heard the ward was missing at least half of its staff on the day Ruth, who had self harmed several times in the past, was left unsupervised.
Mr Acheampong was originally working on a different ward, but was asked to join the team on Thames ward because they were so short-staffed nurses could not go on breaks, jurors were previously told.
A risk management form known as a 'Datix incident' had been filed on the day by Michelle Hancey – a support worker with 18 years' experience at Huntercombe – who raised concerns the Thames ward team would 'fail to monitor patients on prescribed special observation because of staff shortage'.
During the inquest, jurors were shown CCTV footage of the moment Mr Acheampong left Ruth unsupervised while she sat in the ward's lounge watching TV, enabling her to leave the room.
She had been placed on the 'level three observation' plan following earlier incidents of self-harm – meaning she had to be kept within eyesight at all times.
In the footage, Mr Acheampong can be seen leaving the room repeatedly – at first only for seconds at a time, then for two minutes – prompting the teenager to walk up to the door and look into the lobby, seemingly waiting for the opportunity to leave the room.
She was last captured on CCTV walking out of the ward's day room 'completely on her own' before going straight to her bedroom and closing the door behind her, coroner Ian Wade KC told the inquest.
Around 15 minutes passed before a nurse discovered the teenage girl and raised the alarm.
Huntercombe Hospital had been inspected twice by the Care Quality Commission (CQC) prior to the incident, the inquest previously heard.
It was rated as 'overall inadequate' in a CQC report dated February 2021.
Active Care Group, which owned Huntercombe at the time of Ruth's death, has since closed the facility.
Following the inquest, a spokesperson said: 'We extend our heartfelt condolences to Ruth's family, friends, and all those affected by her passing.
'We deeply regret the tragic event that occurred, and we are truly sorry for the distress this has caused and recognise the profound impact it has had on everyone who knew her.
'In recent years, we have made significant improvements to the quality and safety in all of our services.
'We remain fully committed to working closely with our teams across the country to ensure consistently high standards of care for the individuals we support.
'We are dedicated to learning any further lessons through both this inquest process and others from across the NHS and Independent sector with the aim of preventing any future tragic incidents.'