Fatal Failings: Inquest Finds Medical Staff Missed Brain Disorder in 12-Year-Old’s Suicide
A jury has determined that a 12-year-old girl who tragically took her own life after being sectioned was failed by medical professionals who did not identify an underlying and treatable brain disorder. The inquest reveals critical missed opportunities that may have altered the course of Mia Lucas’s devastating outcome.
Mia Lucas was found unresponsive in her room at the Becton Centre, part of Sheffield Children’s Hospital, on January 29 of last year. The inquest centered on whether crucial diagnostic steps were overlooked, ultimately contributing to her death.
Jurors learned that Mia suffered from undiagnosed autoimmune encephalitis, a rare condition characterized by brain swelling and manifesting as “acute psychosis.” The diagnosis only emerged during the inquest itself, revealed by new post-mortem examination results presented by a pathologist.
The central finding of the inquest, concluded on Thursday, was that the failure to perform a lumbar puncture at Nottingham’s Queen’s Medical Centre (QMC) before Mia’s transfer to the Becton Centre “possibly contributed” to her death. This procedure could have detected indicators of the autoimmune condition.
The crisis began over the Christmas 2023 holiday period, when Mia began exhibiting unusual behavior, including auditory hallucinations and physical aggression towards her mother. Growing alarm prompted her family to seek emergency medical attention, leading to her admission to QMC on New Year’s Eve.
There, she was diagnosed with an “acute psychotic episode” and subsequently sectioned under the Mental Health Act. Initial blood tests and an MRI scan at QMC yielded negative results, leading clinicians to dismiss a physical cause for her psychosis. However, crucially, they opted against further investigation, including a lumbar puncture to analyze cerebrospinal fluid – a test that could have revealed the presence of autoimmune encephalitis.
Mia was transferred to the Becton Centre on January 9th and died just three weeks later.
In their detailed narrative conclusion, the jury stated: “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.” The jury also criticized the communication between QMC and the Becton Centre, noting it “provided an inappropriate level of assurance that organic causes had been ruled out.”
Further scrutiny revealed deficiencies in care at the Becton Centre as well. 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.” However, the jurors acknowledged the inherent challenges in diagnosing and treating a “rare presentation of a rare condition.”
The senior coroner for South Yorkshire (West), Tanyka Rawden, directed the jury to record Mia’s cause of death as compression of the neck, resulting from acute psychosis triggered by autoimmune encephalitis.
Following the inquest, Mia’s mother, Chloe Hayes, delivered a powerful statement. “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 said. “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, expressing her anguish: “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 concluded with a heartbreaking declaration: “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, responded with an apology. “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,” Dr. Shehmar stated. “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.”
