A 12-year-old girl who took her own life after being sectioned was failed by medical staff who did not spot her underlying brain disorder, an inquest has found. Mia Lucas was found unresponsive in her room at the Becton centre, part of Sheffield children's hospital, on 29 January last year.
Jurors heard that Mia had undiagnosed autoimmune encephalitis – a rare condition causing swelling of the brain – which explained her 'acute psychosis'. The diagnosis only emerged partway through the inquest after a pathologist received new post-mortem test results.
The inquest jury concluded that the failure to carry out a lumbar puncture at Nottingham's Queen's Medical Centre (QMC) before her transfer to the Becton centre had 'possibly contributed' to her death. Mia began behaving unusually over Christmas 2023, including hearing voices and attacking her mother, and was taken by ambulance to QMC on New Year's Eve. She was sectioned under the Mental Health Act after being found to be experiencing an acute psychotic episode.
Blood tests and an MRI scan at QMC were negative, leading doctors to rule out a physical cause. However, clinicians decided not to request further tests of brain activity or spinal fluid, including a lumbar puncture, which may have revealed the condition. Mia was transferred to the Becton centre on 9 January and died three weeks later.
The jury found that information passed between QMC and the Becton centre provided an inappropriate level of assurance that organic causes had been ruled out, and that at the Becton centre, insufficiently robust communication and management of risk led to a failure to respond adequately to Mia's risk of self-harm. The coroner recorded Mia's cause of death as compression of the neck, caused by acute psychosis, caused by autoimmune encephalitis.
Mia's mother, Chloe Hayes, said: '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.' Dr Manjeet Shehmar, medical director at Nottingham University Hospitals NHS Trust, said: 'We accept the coroner's outcome ... and apologise to Mia's family for not identifying autoimmune encephalitis while she was in our care.'
