Inquest Finds Suicide of 14-Year-Old Girl Could Have Been Prevented

1 October 2021

Simpson Millar’s Public Law team represented the family of teenager Mazielle Mackenzie at an Article 2* inquest investigating the circumstances surrounding her death, which concluded today at Preston Coroner’s Court following a five-day hearing.

Mazielle, who was known to her family and friends as Mazie, had an extensive history of self-harm and had previously disclosed that she had been the victim of sexual abuse.

She was taken into care in 2016 and was admitted as a resident at The Cove in May 2018 – a hospital for young people between the ages of 13 and 18 who are experiencing a variety of mental health problems.

Despite being admitted to the specialist inpatient unit, four weeks later the teenager tragically took her own life on 23rd June 2018. She was just 14 years old.

On the night of her death, she had visited a park as part of a group of young people from the unit. However, instead of returning to the Morecambe facility she ran away and was later found hanging from a swing in a local playground.

An investigation following her death confirmed that the group had only been accompanied by two members of staff.

An inquest into her death which concluded at Preston Coroner’s Court on Friday, October 1st, recorded a verdict of death by suicide.

The inquest also found that Lancashire Care NHS Foundation Trust failed to revisit her formulation and risk management plans when self-harm incidents occurred and did not include Mazie’s needs and how they were to be met.

What the Inquest Found?

The inquest also concluded that:

  1. Her risk assessment held limited risk history and management plans in regard to Mazie's risk of going missing
  2. There was no written standardised procedure for agreeing and facilitating leave
  3. Communication of relevant information and record-keeping did not meet the required standard
  4. There was insufficient staff to supervise children when on leave from the hospital

The Coroner further concluded that with regards to York Child and Adolescent Mental Health Services, there was:

  • A delay in making a referral to place Mazie in a tier 4 placement which was appropriate for her needs
  • A failure by York CAMHS to accept ownership of her case and that during that delay Maize’s mental health deteriorated

Throughout the inquest, the Coroner heard concerns about the level of care that Mazie had received, specifically in relation to the ratio of staff to young people on leave on the date of Mazie's death.

Representatives for the family also highlighted the lack of a risk assessment prior to the decision to permit the group to leave with that staffing ratio and the lack of guidance in Mazie’s care plan regarding circumstances in which she should have leave and how it should be facilitated.

Speaking following the hearing Chris Callender, Head of Claims against Public Authorities, who was acting on behalf of Mazie’s family at the hearing, said: “This is truly tragic case which resulted in the death of a vulnerable young girl who was in desperate need of care, support and protection.

“As was detailed throughout the inquest, Mazie had a long history of self-harm behaviour. She was also a flight risk, having run away more than 20 times in less than a year from the care home where she had been living prior to moving to The Cove.

“Despite this, there was countless evidence to suggest that more could have been done to protect her. Better communication between the relevant safeguarding authorities, more comprehensive risk assessments, and more appropriate supervision.

“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.

“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, and that any changes that have been made are shared across the NHS to help protect other vulnerable young people in the future.

Chris Callendar Partner, Head of Claims against Public Authorities

Mazie had been known to Cumbria children’s services since she was just 11 months old. She had a history of self-harm, including cutting herself, and ingesting harmful substances while in foster care and in residential care.

Her attempts to harm herself escalated to include ligatures, at which point she was transferred to The Cove in May 2018 for additional supervision and support.

The inquest heard that Mazie was well-loved by everyone who knew her. She was a talented musician and extremely caring. Her mother told the Court she was proud to be Mazie’s mum. Her life is better for having had Mazie in it even though Mazie is gone. She will always be Mazie’s mum and will never stop loving her and missing her.

*Article 2 inquests take place when a death occurs in custody or if there is a belief that the state has failed to take steps to protect an individual.

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