A teenage girl who was found dead after going missing from a mental health unit “was failed by health services”, a coroner has said.
Maziellie MacKenzie was found unresponsive in a coastal woodland area on June 23 in 2018 after running away from The Cove in Heysham where she had been admitted three weeks earlier after a series of incidents of self-harm.
The 14-year-old, from Barrow-in-Furness, had a turbulent upbringing and social services were involved with her and her mother Wendy MacKenzie from when she was a baby. Social workers raised concerns about the neglect Mazie suffered as well as her mum’s contact with two ex-partners Gary Hamilton and Dan Szweda.
Mazie’s early childhood was characterised by “inconsistency, neglect, instability, rejection and abandonment”, an expert said today (September 29) while giving evidence during the third day of an inquest into her death.
She had been placed in foster care in May 2016 when she was 13 but around this time she revealed she had been sexually abused since the age of seven. She was considered to be at high risk of further child sexual exploitation and she said she had been abused by a drug dealer in order to pay off a cannabis debt.
In May 2018 Mazie moved to a specialist residential home for victims of child sexual exploitation in Yorkshire but after a number of concerning incidents she was admitted to York Hospital on May 15 in 2018. She did not receive a mental health assessment before being discharged.
The following day after telling staff at the home in Yorkshire that she wanted to die she was admitted to Pinderfields Hospital in Wakefield where she spent three weeks “in limbo”, social services manager Keeley Slack has said during the inquest, while the various hospital trusts “argued” over who should complete a form to refer her to a specialist mental health unit.
On June 23 in 2018 after being admitted to The Cove, a mental health unit in Heysham for teenage girls, Mazie ran away while on a trip to the local park with three other girls. Six hours later police found her body in Heysham Barrows.
Dr Amith Paramel, a consultant psychiatrist with Lancashire and South Cumbria NHS Foundation Trust, said a number of “issues” had been identified as part of a Learning Review conducted into Mazie’s care during her three weeks at The Cove.
“A number of themes were flagged up for improving quality of care after Mazie’s death,” Dr Paramel said at the inquest today (September 29).
“Staff have been given training since her death in risk management and big changes have been made regarding leave arrangements.”
Group outings are no longer routinely allowed at The Cove and leave is now staggered so that young people are not able to “collaborate to run away” as happened when Mazie went missing, Dr Paramel said.
However, Dr Paramel explained that even when patients are detained under the Mental Health Act, staff cannot physically restrain them or prevent them from absconding unless there is an immediate risk of harm. Mazie was a voluntary patient and, as such, she was free to leave if she wanted to.
“Mazie was granted escorted leave but she was escorted not because it was felt she was a risk to herself but because she was at risk of being sexually exploited,” he added.
“Granting her leave was a reasonable decision. It is important young people have access to activities and normal day-to-day life outside of The Cove. Young people need to have experiences as close as possible to normal life. With the benefit of hindsight I would say (the group of girls shouldn’t have been granted leave) but given the fact some of them had gone out as a group earlier that day without incident it would have been very difficult for staff to have refused.”
Assistant Coroner Phil Holden said: “It’s a shame, in one way, because people have forged relationships and can no longer share activities outside of The Cove.”
Refusing group outings has not been written down in The Cove’s formal policy, Dr Paramel explained, because “the Care Quality Commission (which regulates healthcare settings) would frown upon that and see it as a blanket ban”. Dr Paramel did accept that the staff to patient ratio on the group outing, with two members of staff to four patients including one who was detained under the Mental Health Act, “wasn’t sufficient”.
The Cove no longer allows patients to visit the playground which Mazie went missing from and staff have a closer working relationship with the local police.
During today’s proceedings the coroner indicated that he intended to make reference to several failings in Mazie’s care during his conclusion.
“There are admitted failings from when she went into York Hospital and there was then the delay when she was at Pinderfields Hospital in which no ownership was taken for the referral to The Cove,” he said.
“She was failed by those health services.”
Consultant forensic psychiatrist Irfan Rafiq, who works for Cygnet Health and is often called as an expert witness in court proceedings, agreed that Mazie should have had a mental health assessment at York Hospital.
“Would you have expected someone presenting like that to have undergone a full mental health assessment?” the coroner asked him.
“One hundred per cent,” Dr Rafiq replied.
“Mazie had a history of instability, an unstable relationship with her mother, inconsistency, rejection and abandonment.”
“York and Scarborough Teaching Hospitals NHS Foundation Trust has accepted that and that there wasn’t even a referral to their own psychiatric team in the hospital,” the coroner added.
The inquest at Accrington Town Hall, which started on Monday, has heard that there were 11 ongoing police investigations into the allegations she had been sexually abused at the time of Mazie’s death. No arrests have ever been made in connection with the alleged abuse she suffered.
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