Grace Smith, aged 16, passed away on August 5, 2022, at Rainbows Hospice for Children and Young People in Loughborough following a self-inflicted ligature at St Andrew’s Healthcare in Northampton.

An inquest jury determined that Grace’s death resulted from suicide, influenced by a failure to adequately address her risks and triggers despite available information. The jury highlighted a missed opportunity to provide appropriate care.

Born in Milton Keynes, Grace was a thoughtful, caring, kind, and loving daughter, always considering the well-being of others.

Factual Background

Grace faced a complex history of mental health challenges, including bipolar disorder, an eating disorder, severe self-harm, suicide attempts, and post-traumatic stress disorder.

In December 2021, Grace was admitted to Beacon Ward, a CAMHS general adolescent inpatient unit. Due to her high risk of self-harm, she was initially under constant 1:1 observations, later reduced to checks every 5 and then every 10 minutes.

On the day her observations were reduced to 10 minutes, Grace made a significant suicide attempt, necessitating hospital treatment before returning to the unit. Her observations were then increased back to constant 1:1.

Grace later confided to her psychologist that she had planned her attempt and waited for the reduction in observations. She had a known history of concealing her suicide risks.

Grace continued to self-harm, and on January 18, 2022, she was transferred to St Andrew’s Hospital, a low secure unit in Northampton, as she could no longer be safely managed on Beacon Ward.

On January 19, 2022, Grace’s community home, Almond Care, served notice on her placement. Grace was informed the following day. All staff involved acknowledged that this news would significantly increase her suicide risk, as she was likely to feel hopeless and ‘stuck’ in the hospital. Consequently, St Andrew’s staff placed Grace on constant 1:1 observations.

Grace’s community psychologist, who had worked with her for years, testified that Grace’s risk would remain high until her community placement issue was resolved.

Grace experienced continued incidents of self-harm and further suicide attempts after receiving the news. In the days leading up to her death, while Grace had been self-harm free, she exhibited aggression towards staff and was noted to be experiencing paranoia and hallucinations—recognised risk factors for her declining mental health.

On February 10, 2022, a Care Plan Update Meeting was held involving staff at St Andrew’s Hospital and two community professionals. Following this meeting, Grace’s observations were reduced from constant 1:1 to 15-minute checks for a trial period of 1 hour per day, between 12:00 and 13:00.

Staff at St Andrews testified that they did not consider additional measures necessary alongside the reduction. The meeting minutes did not document any direct discussion of the incidents of aggression, paranoia, or hallucinations.

The inquest revealed that not all attendees of the Care Plan Update Meeting were aware of the decision to reduce Grace’s observations. Grace’s social worker from Lincolnshire County Council stated she did not believe they had made the decision during the meeting. Had she known, she would have wanted to ensure the decision was safe and would have consulted Grace’s community psychologist.

At 12:00 on February 11, 2022, Grace’s observations were reduced. During this period, she sat alone in an empty room with the door closed, out of the CCTV’s view.

Staff reported conducting checks more frequently than every 15 minutes due to concerns about Grace’s risk. However, CCTV footage shown during the inquest revealed that the 12:35 check lasted approximately six seconds. Grace’s family has raised concerns about the brevity and quality of these checks.

At 12:47, staff found Grace unresponsive after she had ligatured. A medical emergency was declared, and she was transported to the hospital by paramedics.

On February 14, 2022, scans indicated Grace had suffered a hypoxic brain injury with a poor prognosis for recovery. She was later transferred to Lincoln General Hospital and, on July 22, 2022, to Rainbows Hospice for end-of-life care. Grace died on August 5, 2022.

Inquest Findings

Over five days at Northampton Coroners Court, the jury examined evidence regarding Grace’s care at St Andrews, particularly the decision to reduce her observations. The jury found a failure to adequately consider Grace’s risks and triggers given the known and available information, resulting in a missed opportunity to provide appropriate care.

The jury concluded that Grace died as a result of suicide, influenced by the inadequate consideration of her risks and triggers.

Rachel Smith, Grace’s mother, said: “Grace had so much planned for her future. She was bright, funny, caring, and so much more, but because of what happened at St Andrew’s, her future was taken away from her. The failings at St Andrew’s that the jury found to have contributed to my daughter’s death could have been prevented. My heart aches every day, knowing she’d still be here if they had done things right. My amazing Grace will never be forgotten and will always be loved forever.”

Grace leaves behind her twin sister, Reanne, who is utterly heartbroken by Grace’s death.

Megan Spurr, at Ison Harrison Solicitors, stated: “This is an extremely sad case involving a vulnerable young woman. Grace had self-harmed on numerous occasions before her admission to St Andrew’s Hospital and was clearly a high-risk patient with a history of waiting for her observations to be reduced to make an attempt on her life. Despite this high-risk behaviour, and her known history of using reductions in observations to ligature, the decision was made to trial reducing those observations to only four checks per hour for an hour a day. Sadly, Grace’s death is one of many at mental health inpatient units across the country.”

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