A charity is calling for an urgent review of children’s mental health services after a coroner ruled that a hospital’s failings led to a schoolboy’s death.
Christopher Brennan, 15, died after being found unconscious at Bethlem Royal Hospital in south London in August 2014, six weeks after he was admitted for self-harm and mental health problems.
He had a history of self-harm and suffered a deterioration in his mental health over the two years prior to his death.
An inquest at South London Coroner’s Court found that staff became “desensitised” to his self-harm.
He was also allowed access to a number of items in hospital which he used to self-harm. Furthermore, the coroner also found that no formal risk assessment had been carried out during his stay and that there was no care plan in place.
Coroner, Selena Lynch, said: "Christopher's actions were in part because of cumulative and continuing failures in risk assessment and management. His death was contributed to by neglect."
According to INQUEST, the charity supporting his family, Christopher was one of at least 11 young people to die in psychiatric units in England between 2010 and 2014.
In a statement released to the Press Association following the inquest, Christopher's 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.”
Director of INQUEST, Deborah Coles, added: "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."
A spokesperson for South London and Maudsley NHS Foundation Trust, which runs Bethlem hospital, said: "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.”