It could be argued that from the moment she was born on July 15 in 2003 Maziellie MacKenzie’s life was destined to be one filled with sadness, abandonment and betrayal.
Mazie’s short life, which ended when she took her own life at the age of just 14, was described in detail this week during an inquest at Accrington Town Hall.
Mazie’s mum Wendy Louise MacKenzie, who had a history of heroin use, struggled from the outset and, just 11 months after Mazie was born, the pair were found sleeping in a car.
When social services became aware of their circumstances Mazie was placed in temporary care for a month. When she returned to her childhood home in her hometown of Barrow-in-Furness the authorities had no alternative but to step in, on numerous occasions, amid fears for her safety. When she was just five, an age at which most youngsters are afforded the innocence of youth, Mazie told a social worker that her mum was using drugs.
When Mazie was eight, social services flagged up concerns about her mum’s drinking and use of drugs and three years later, in September 2014, Wendy was arrested on suspicion of child neglect.
At this time Wendy was seeing a man – someone who social services had “grave concerns about”.
There was a “significant pattern of alcohol consumption” and arguments between Wendy and Gary and their “lack of understanding about how it affected Mazie”, official records later revealed. Although Wendy tried to improve the environment in which Mazie was being brought up her daughter’s emotional state continued to deteriorate.
By 2016, when Mazie was 13, social services acknowledged that the time had come to take their intervention to the next stage and through the family court obtained an interim child protection order; and later a full care order, to retain custody of Mazie, a process which mum Wendy did not oppose. From then on Mazie became what is known as a ‘looked-after child’.
Between May 2016 and July 2017 Mazie was placed with three different foster families in Barrow and Dalton but each placement eventually broke down because of her complex emotional needs and behaviour. She spent eight months in a children’s home in Barrow, between July 2017 and March 2018, during which time it became apparent that Mazie was in urgent need of more intensive support.
After repeated and regular instances of Mazie going missing she disclosed that she was being sexually exploited by drug dealers in order to pay off cannabis debts. Mazie also revealed she had been sexually abused by numerous men from the age of seven. Mazie’s mum refused to believe her and called her daughter a liar.
Despite their inclination to allow Mazie to remain close to her hometown of Barrow, particularly given the way in which she was thriving and engaging at school, bosses at Cumbria County Council’s social services came to realise that Mazie needed more help than they were able to provide.
In May 2018, aged 14, Mazie moved to a specialist residential care home for victims of child sexual exploitation in Yorkshire. She quickly settled in and became good friends with a resident. Staff at the home developed a close bond with Mazie.
But Mazie was unable to escape her past and the alleged abuse she had suffered at the hands of those she should have been able to trust. She told staff at the home how she had been sexually exploited when she was younger.
The allegations were formally reported to Cumbria Police. But nobody was ever arrested in connection with the 11 investigations which were ongoing at the time of Mazie’s death. Just a few weeks before she died Mazie claimed she had been told by police that they would not pursue the allegations while she was a patient in a mental health unit. Cumbria Police has since disputed this.
By the middle of 2018 Mazie’s self-harming had escalated. Staff at the home in Yorkshire no longer felt they could keep her safe. On May 14 ,Mazie was left distraught after speaking to her mum on the phone and hearing the voice of Wendy’s ex in the background. “She couldn’t believe her mum had got back with him”, the inquest heard.
The following day, as a result of her distress at discovering her mum was back with her ex, Mazie was taken to York Hospital in May 2018 but doctors failed to follow policy and did not undertake a full mental health assessment or refer Mazie to the Child and Adolescent Mental Health Services.
It was then recognised that Mazie needed to be placed in what is known as a Tier 4 unit – an in-patient setting for young people with complex mental health needs, but the various hospital trusts which had been involved in her care couldn’t agree which of them should fill in the form to refer her to such a place. Mazie was originally from Cumbria but when admitted to York Hospital had come under the care of York and Scarborough Teaching Hospitals NHS Foundation Trust and, latterly, that of Mid Yorkshire Hospitals NHS Trust when she was admitted to Pinderfields Hospital in Wakefield.
This disagreement led to Mazie being left in limbo, in a children’s ward at a hospital in Wakefield, for three weeks.
Eventually the clinical director of Cumbria’s Child and Adolescent Mental Health Services, Barry Chase, decided enough was enough and, disregarding protocol, put his name to a referral which would allow Mazie to move to The Cove in Heysham. Sadly this was to be an admission which led to Mazie taking her own life.
Three weeks after moving to Heysham Mazie went on a trip to a nearby playground, on June 23 in 2018, along with three other girls and two members of staff. When the girls refused to return to The Cove and ran away from the two healthcare assistants Mazie also went AWOL. Faced with the impossible decision of who they should prioritise the two members of staff ended up losing sight of Mazie.
Within the space of around 20 minutes the other girls were found, and agreed to return to The Cove, but Mazie was nowhere to be seen. The last sighting of her was at around 7pm when a nurse from The Cove spotted Mazie on the bypass while on her way into work. Mistakes in how Mazie’s disappearance was logged by Lancashire Police meant that it was almost two hours before officers began searching for her.
At just after 10pm, less than four hours after Mazie had disappeared, a group of teenagers came across her body in a secluded woodland area known as The Barrows. Despite the desperate efforts of police officers who were first on the scene, and who tried to resuscitate her, Mazie was pronounced dead at 11.03pm.
The biological mechanism by which Mazie died; compression of the neck, offers the only possible solace anyone might feel able to identify. Mazie would have lost consciousness in as little as 1-2 seconds and after one minute any efforts to resuscitate her would have been futile.
But that doesn’t make Mazie’s death any less tragic.
While no individual failing, when considering the countless mistakes and missed opportunities of the health trusts and agencies involved in Mazie’s care, can reasonably be considered, even on the balance of probabilities, to have been responsible for her death it is clear that the catalogue of errors contributed to the desperation Mazie found herself in.
Despite not being satisfied that any of the failings caused or contributed to Mazie’s death the coroner did accept that, had another member of staff been with the group of girls when Mazie ran away, it is possible that the outcome “might have been different”.
After the conclusion of the inquest into Mazie’s death a spokeswoman for Cumbria Police told LancsLive that the evidence heard during the hearing – and more specifically the claim that Mazie had been told police would not pursue the allegations of sex abuse while she was a patient in a mental health unit, was not accurate.
“The allegations of serious sexual offences were still under investigation at the time of Mazie’s death and the constabulary tried to pursue these after her death as well,” the spokeswoman said.
“Any communication with Mazie was done via a social worker and was not direct from Cumbria Police due to her vulnerabilities.
“Extensive enquiries were conducted during the 11 investigations and they were thoroughly investigated and reviewed by senior officers.”
Temporary Detective Superintendent Dan St Quintin, from Cumbria Police, said in a statement: “Protecting children and vulnerable people is a key priority for the constabulary and is an area which we continually review to ensure our approach is effective in keeping people safe.
“The serious case review identified learning points concerning how we shared information with other agencies previously. As part of a continuous review of our procedures, we have improved our information-sharing processes when children are moved to other areas of the country to be cared for.
“Any loss of a child is tragic and our thoughts are with the family at this time.”
Assistant Coroner Phil Holden, who presided over this week’s inquest, is set to hold a further hearing, before the end of the year, in order to satisfy himself that the various health trusts which failed Mazie, under the threat of being issued with a Prevention of Future Deaths report, have made sufficient improvements.
A spokesperson for Lancashire and South Cumbria NHS Foundation Trust, which is responsible for The Cove in Heysham, said: “We would like to reiterate our deepest sympathies to Mazie’s family and friends. We appreciate that any inquest is difficult for the loved ones involved, and particularly so when the death is that of a young person.
“Since this tragic event in 2018, we have used the learning from our investigation to make improvements in the unit, for example, how we manage escorted leave. The safety of our service users is our top priority, and we are committed to continually improving.”
Lancashire Constabulary has told LancsLive they will issue a response to our request for a comment regarding the issues the coroner raised about the way Mazie’s disappearance was investigated in the coming days.
The coroner said at the conclusion of the inquest that he did not intend to write a Prevention of Future Deaths report in relation to York and Scarborough Teaching Hospitals NHS Foundation Trust, which runs York Hospital, because he was satisfied comprehensive improvements have been made since Mazie’s death.
A spokesperson for the York trust said: “The trust regrets any anxiety caused to the staff of the residential home following Mazie’s discharge from the emergency department without a CAMHS assessment.
“Following an internal enquiry the Trust accepted at the inquest that should not have happened. At the time Mazie had no physical injuries needing treatment and the doctor understood staff were content to take her back to the residential home and contact the CAMHS service, which is provided by a different NHS Trust, later that morning.
“The coroner accepted that the trust has undertaken a meaningful review and has changed its policies and procedures appropriately.”
Mid Yorkshire Hospitals NHS Trust did not respond to our request for a comment regarding Mazie’s admission to Pinderfields Hospital in Wakefield.
After the conclusion of the inquest, in which the coroner ruled Mazie’s death was a suicide, Chris Callender, who represented Mazie’s family during the hearing, said that although improvements had been made at the various health trusts involved in the case it was “too little too late” for Mazie.
“The coroner’s findings show that had there been robust procedures in place and more staff at the time then Mazie’s death could possibly have been avoided,” Mr Callender told LancsLive.
“While it is evident that lessons have been learnt from this terrible tragedy, it is sadly too little too late for Mazie.
“It is the family’s hope that her death has been a catalyst for change, however, and that any changes that have been made are shared across the NHS to help protect other vulnerable young people in the future.”
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