Madeleine Savory: 15-year-old who died at Ipswich Hospital was victim of multiple failures
Madeleine was waiting for a mental health bed when they died
Last updated 9th Aug 2023
A 15 year old who took their own life while waiting at Ipswich Hospital for a bed at a mental health unit was failed by NHS staff and her school, a coroner has found,
Madeleine Savory passed away in February 2022, over two weeks after being admitted.
Suffolk Coroner Darren Stewart ruled there were "multiple failings" and "poor decisions" by staff at Ipswich Hospital, and the availability of mental health beds "more than minimally contributed to Madeleine's death."
He also outlined failings at Madeleine's school at Norfolk and Suffolk Foundation Trust, which is responsible for local mental health services.
Madeleine's family say her death was 'entirely foreseeable and preventable'.
Dr Angela Tillett, Chief Medical Officer at East Suffolk and North Essex NHS Foundation Trust said:
“Everyone involved with Maddie’s care is deeply saddened by the tragic event. We have made significant changes in how we care for young people with mental health issues since 2022 and remain committed to working in close partnership with our mental health colleagues.
"We offer our deepest sympathy and condolences to Maddie’s family.”
Madeleine was under the care Norfolk and Suffolk NHS Foundation Trust (NSFT), the trust responsible for local mental health services, at the tme of her death.
Cath Byford, Deputy Chief Executive of NSFT said: “Madeleine’s death was a tragedy, and we extend our deepest condolences to their family.
“We know this inquest and today’s conclusion will have further added to their anguish.
“We are committed to working with our health partners to learn from Madeleine’s tragic death.“
Rowena Mackie, Headteacher of Northgate High School said:
“We miss Madie very much and their loss has been felt across the school community.
“We acknowledge the coroner’s conclusion and as presented at the inquest we acted swiftly to review all our safeguarding arrangements.
"We have implemented several changes as a result.
“Our thoughts are with Madie’s family during what we know must be a very difficult time."
Failures in school safety plan contributed to self harm
Madeleine Savory, who used they/them pronouns, was 15 years old when they died at Ipswich Hospital in late February 2022.
They were initially admitted after causing harm to themselves on 3 February 2022 after leaving Northgate High School during school hours.
Despite safety measures in place, it was revealed in the inquest the school did not raise an alarm about their absence for nearly two hours.
The coroner determined Madeleine was failed by their school, who appeared to care more about GDPR than the plan for the 15 year old's safety.
He said they had "failed to effectively implement the safety plan for Madeleine specifically designed to keep Madeleine safe".
Madeline was placed in the Bergholt ward at Ipswich Hospital whilst waiting for Tier 4 bed to become available on the 7th of February
At the time, they were under the care of Norfolk & Suffolk NHS Foundation Trust (NSFT).
"Distressing delays in provisional care for children"
The inquest, at Suffolk Coroners Court, heard that increased pressure on the NHS meant it was difficult for staff to keep up with policies, which impacted Madeline's care.
Madeleine was assessed on 21 October, when it was established they suffered from anxiety, low mood gender dysphoria, and had issues around food.
The staff were aware that Madeline was at a 'high risk' of self-harm and had multiple incidents between September 2021 and February 2022.
However, Consultant paediatrician Dr Mariette Fernando told the Coroner's Court that staff were not fully aware of the patient's specific risks of self-harm and it was often assumed everyone knew what was going on.
The inquiry also revealed a risk assessment took place on the 12th of February 2022 which identified the need for additional measures for Madeline.
In his conclusion, Coroner Darren Stewart said there was a 'naivety' in the staff when addressing Maddy's mental health conditions, which meant staff on the ward did not fully understand the risks to Madeleine or how to manage them.
Mr Stewart also noted the lack of availability for a Tier 4 bed was at the 'heart of the inquest.'
He said that this was no fault of the staff due to a national shortage, with the average wait times in the East of England being 46 days.
However, "the absence of adequate resources for timely allocation resulted in Maddy being accommodated on an Acute Paediatric ward which 'possibly more than minimally contributed to madeleines death.'
But Mr Stewart said the availability of a tier four bed nationally was "at the heart of the inquest".
Madeleine had been on a waiting list for a bed for 12 days when they made an attempt on their life.
"Indescribable pain and torment"
In a statement outside Suffolk Coroners Court, a lawyer for Madeleine's family said it was "particularly distressing" to hear of Madeleine being treated on a ward with an "amateurish and incompetent approach to mental health, safeguarding and risk".
The family maintains that Madeleine's death was "entirely foreseeable and preventable" and say they "hope that lessons will be learnt to avoid another child and family having to go through the indescribable pain and torment we have endured."
The coroner paid tribute to Madeleine's parents them for their "advocacy", and "attention to doing the best for their children."
Mr Stewart said he was "incredibly touched in the manner" the parents had conducted themselves and they behaved "in a dignified and respectful manner."