Girl left unwatched by agency worker at psychiatric unit was unlawfully killed, inquest finds

The Guardian

19 hours ago

A vulnerable 14-year-old girl was unlawfully killed when an agency support worker failed to keep her under observation at a secure psychiatric unit, an inquest jury has concluded.
The worker, who used a false identity, left Ruth Szymankiewicz alone even though she had complex mental health issues and was judged to need constant watching because she was a suicide risk.
Ruth was able to slip back to her room and harmed herself at the privately run Huntercombe hospital near Maidenhead on 12 February 2022. She died two days later.
During the inquest it emerged that the worker, who went under the stolen identity Ebo Acheampong, had never worked at any hospital before the day he was put in charge of observing Ruth and did not receive an induction before his shift.
The jury at Beaconsfield raised concerns about training of agency staff at Huntercombe and said contributing factors to Ruth's death included her not being prevented from accessing the material she used to harm herself.
She did not receive therapy that may have helped while she was being detained under the Mental Health Act, family visits were limited though they may have helped her wellbeing and she was able to access harmful material on her phone, the jury heard.
Speaking after the jury returned its findings, Ruth's parents, Kate and Mark Szymankiewicz, who are respectively a GP and a consultant surgeon from Wiltshire, said: 'There is an empty space at our table, a silent bedroom in our home, a gaping hole in our family that will never be filled.
'Ruth was an incredible, bright, friendly, loving and adventurous girl with a whole life of joy ahead of her. She, like many other teenagers, developed an eating disorder.
'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. As a child who thrived on her connection with nature, she was essentially caged.
'Over the last two weeks, we have heard about the numerous systemic failures at Huntercombe hospital,' the family said. 'It would be easy to be distracted by the failings of one individual. However shocking that conduct might have been, it is paramount that the other wider and more important issues are acknowledged and addressed.'
Health experts told the Guardian that many of the issues around the use of agency staff and the shortage of psychiatric intensive care units for children and young people was still a huge problem.
Andrew Molodynski, the British Medical Association's mental health lead, said there was a 'gap in accountability' over the training and vetting of agency staff. He said it was often mental health inpatient units, with the most high-risk individuals, that relied on agency staff the most, especially when they had patients like Ruth needing one-to-one supervision.
He said this was a 'toxic catch-22 … You end up with very few people who know the ward and know the patients'.
Minesh Patel, an associate director of policy and campaigns at the mental health charity Mind, said Ruth's case was 'a clearcut example of the many systemic issues in our mental health hospitals'.
He said: 'An overreliance on agency staff can compromise patient safety, quality of care, and in the worst cases lead to serious harm or loss of life.'
During the inquest, Dr Gillian Combe, the clinical director for the provider group that commissioned Ruth's placement, said the understaffing seen at Huntercombe still existed.
She expressed frustration at rules in England that make it hard for new NHS units to be built, meaning provider groups have to rely on sending patients to private units.
Combe said this situation arose after Andrew Lansley's changes to the NHS – described by some as 'creeping privatisation' – when he was the health secretary from 2010 to 2012. She said there were no psychiatric intensive care units for children and young people in the whole of south-west England.
Jodie Anderson, a senior caseworker at the charity Inquest, said: 'The jury's findings are a stark indictment of a mental health system that sent a vulnerable child far from home to a private unit with dangerously inadequate care.'
Dr Amit Chatterjee, the chief medical officer at Active Care Group, which owned and ran Huntercombe, told the inquest that the company had worked hard to improve recruitment and its induction process.
Huntercombe has closed but Chatterjee said the company had increased therapeutic care at its current site for young people, Ivetsey Bank hospital in Staffordshire.
The inquest heard that after learning that Ruth had died, the worker known as Acheampong fled from the UK to Ghana. Thames Valley police said they knew his real identity but did not have enough evidence to try to get him back.
The use of agency staff in mental health settings has been cited as a big problem in numerous reviews and inquest conclusions. In the case of Lily Lucas, a 28-year-old woman who died in 2022 from excessive fluid intake brought on by schizophrenia, an NHS review found that some agency nurses on her privately run ward did not know how to use 999.
A Care Quality Commission report on the Mental Health Act said patients had described agency staff as 'not friendly' and 'less caring' towards patients, and detrimental to morale among permanent staff.
In the UK, the youth suicide prevention charity Papyrus can be contacted on 0800 068 4141 or email [e-mail], and in the UK and Ireland Samaritans can be contacted on freephone 116 123, or email [e-mail] or [e-mail]. In the US, the National Suicide Prevention Lifeline is at 988 or chat for support. You can also text HOME to 741741 to connect with a crisis text line counselor. In Australia, the crisis support service Lifeline is 13 11 14. Other international helplines can be found at befrienders.org