Inquest Reveals Systemic NHS Failings in Tragic Death of 12-Year-Old
An inquest jury has concluded that inadequate testing by the NHS possibly contributed to the death of 12-year-old Mia Lucas, who took her own life while detained under the Mental Health Act. Her mother, Chloe Hayes, has stated she will never forgive the doctors and trusts involved for failing her daughter.
A Rare Condition Missed
Mia Lucas was found unresponsive in her room at the Becton Centre in Sheffield, part of Sheffield Children’s NHS Foundation Trust, on 29 January 2024. The inquest heard that Mia was suffering from undiagnosed autoimmune encephalitis, a rare swelling of the brain that was causing her acute psychosis.
The shocking diagnosis only emerged during the nine-day inquest when a pathologist presented new post-mortem test results. Mia's family, present in the public gallery, were reduced to tears by the revelation.
The jury found that a failure to perform a lumbar puncture at Nottingham's Queen’s Medical Centre before her transfer to the Becton Centre was a critical error. This test could have identified the encephalitis.
A Mother's Anguish and a System's Apology
In a powerful statement, Chloe Hayes described how her daughter was badly let down when she needed specialist healthcare for the first time. She accused the Queen’s Medical Centre of dismissing Mia and passing her to mental health services too quickly.
She further criticised the Becton Centre, stating it was completely unsuitable and failed to keep her daughter safe. Mrs Hayes insisted that Mia's extreme behaviour was only present in the final weeks of her life, and for the previous 12 years, she was a beautiful soul who loved life and her family.
Both NHS trusts involved have issued apologies. Dr Manjeet Shehmar, Medical Director at Nottingham University Hospitals NHS Trust, said the trust was truly sorry for not identifying the condition. Dr Jeff Perring of Sheffield Children’s NHS Foundation Trust also expressed being deeply sorry for Mia's death.
Coroner to Escalate Concerns to Health Secretary
The senior Sheffield coroner, Tanyka Rawden, announced she would be writing to Health Secretary Wes Streeting and several professional bodies. Her concern is the lack of national guidance for testing for autoimmune encephalitis.
The jury's narrative conclusion highlighted the particularly complex challenges in diagnosing such a rare condition. However, they also found an insufficiently robust communication and management of self-harm risk at the Becton Centre.
Mia's case began over Christmas 2023 when she started hearing voices and exhibited strange behaviour, leading to her admission to QMC on New Year's Eve. She was sectioned after being diagnosed with an acute psychotic episode. Despite initial tests, crucial further investigations were not pursued.
The coroner acknowledged changes made at the Becton Centre since Mia's death but will consider writing to Nottingham University Hospitals after their internal investigation concludes.
