Cumulative failures in risk assessment and management meant neglect contributed to the death of a teenager at a mental health unit, a coroner has found.

Christopher Brennan, aged 15, died on August 31, 2014, while an inpatient at Bethlem Hospital’s adolescent unit, which is run by South London and Maudsley NHS Foundation Trust (SLaM). 

Christopher had been admitted to the Bethlem Hospital 6 weeks earlier after a number of incidents of self-harm, which had led his family and Greenwich CAMHS (run by OXLEAS Trust) to feel unable to keep him safe at home. In the previous 2 years, Chris’ mental health had markedly deteriorated, resulting in self-harm and a number of hospital admissions. 

Notable failures by Bethlem hospital were acknowledged as significant contributors to his continued self-harming and ultimately, his death:

No formal, documented risk assessment was produced at any time during Chris’ 6 weeks in hospital

No care plan existed

Chris was allowed access to materials that he could use to self-harm.

The Coroner, Selena Lynch, said in her narrative conclusion: “Christopher’s actions [on the day of his death] were in part because of cumulative and continuing failures in risk assessment and management. His death was contributed to by neglect.”

In a statement, Chris’ family said: "Losing our beloved son and brother when he was just 15 years old was so painful. Losing him as a result of the hospital's failure to protect his life is unbearable. Chris will never be forgotten and no other child should be allowed to die in this way."

National scandal

Deborah Coles, director of INQUEST said: “Chris was an extremely vulnerable young child who was in hospital because of his high risk of self-harm and where he should have been safe. The multiple and inexcusable failings in his care allowed Chris to endanger himself many times over.

“Sadly Chris’s death is not an isolated one. He is one of at least 11 child deaths of mental health in-patients INQUEST has identified between 2010 and 2014. Incredibly, we find that no single body is responsible for collating, analysing or publicising these deaths and that these deaths are not being independently investigated. The lack of resourcing of child and adolescent mental health services across the country is a national scandal.

“The only possible response to this case and the growing public outcry and disquiet around mental health services for children and young people is for an urgent independent review. We call upon the government to now take this necessary step.”

Tony Murphy from Bhatt Murphy Solicitors, acting on behalf of the Brennan family, added: “Deaths in psychiatric hospitals are not investigated by an independent body pre-inquest, which means that Coroners have to rely on evidence gathered by the very organisation under investigation. Jeremy Hunt should not allow mental health trusts to investigate themselves in this way, not least in such a shocking death as Christopher’s.”

In response, a spokesperson for SLaM said: “We offer our sincere apologies to Christopher’s family for their loss. Areas of learning for the Trust were identified through a serious incident investigation and we have carefully reviewed our procedures accordingly. More recently, the service has been inspected by the Care Quality Commission and care was found to be of a ‘good’ standard. We hope this offers some reassurance to the family that lessons have been learnt from this very tragic event.”