Unit failures probably contributed to Lucy Curtis death – inquest

The jury found that the Riverside Adolescent Unit’s failures to recognise her increasing self harm and observe her accordingly “probably contributed” to her death.

It also concluded the failure to adhere to the 15-minute observation and delays in delivering emergency treatment until paramedics arrived possibly contributed to her death.

Dr Michelle Cox, director of Avon and Wiltshire Mental Health Partnership NHS Trust (AWP), told the inquest the Riverside closed because it was not safe following Lucy’s death and other patient safety incidents.

Area Coroner for Avon Peter Harrowing accepted the trust had learned lessons from Lucy’s death by acting upon independent reviews and was satisfied he did not need to make further recommendations.

“I heard from Dr Cox many of those recommendations have been addressed and work is ongoing to address and make improvements,” he told the court.

A spokesperson for AWP said: “We are deeply sorry for the failures in Lucy’s care that contributed to her death.

“Lucy should have been safe in our care, and we failed in that duty. We accept the inquest’s conclusions in full,” they said.

“Our thoughts remain with Lucy’s family and loved ones, and we apologise directly to them. We acknowledge the strength and dignity they have shown and will offer any support they need.”

“We are committed to embedding and sustaining the changes identified through the reviews that have taken place,” it said.

The trust said it was “assessing options” for a new inpatient CAMHS unit, based around the lessons from Lucy’s death.