Ipswich parents of Madeleine Savory react after inquest

Madeleine Savory, who identified as non-binary and used they/them pronouns, was admitted to the Bergholt Ward, a pediatric ward at East Suffolk and North Essex NHS Foundation Trust-run Ipswich Hospital, on February 3, 2022, after they absconded from school and self-harmed.

They were placed on a list for a 'tier 4' bed in a mental health unit on February 7 but, on February 19, they made an attempt on their life while in the ward toilet, and died on February 26.

Madeleine had a five-month history of self-harm, low mood, food restriction and gender dysphoria and had been under the care of Norfolk & Suffolk NHS Foundation Trust (NSFT) after a hospital admission in September 2021.

At Suffolk Coroner's Court on Monday, coroner Darren Stewart identified failings in the care of Madeleine both within the Bergholt Ward and at Northgate High School, where they were a pupil. 

The court heard evidence that Madeleine, whose whereabouts was meant to be monitored while on the school premises, was absent for a total of 110 minutes on February 3 before teachers were alerted by their school friends. 

A supply teacher was covering Madeleine's lesson that day, and the court heard supply staff at the school would not be informed about specific care plans for children due to a previous GDPR incident. 

Madeleine being unaccounted for was also missed by two absence officers who, due to a misunderstanding, only realised they weren't present around the same time their friends informed a teacher.

Mr Stewart said this failure to effectively implement the safety plan designed to keep Madeleine safe during school hours, made a 'more than minimal' contribution to Madeleine's death. 

He also found failings on the Bergholt Ward where Madeleine was being treated.

These including the failure to implement relevant joint policies put in place by ESNEFT and NSFT which specifically dealt with children with mental health issues, probably contributed to their death. 

In evidence throughout the inquest, the court was told staff had not fully checked Madeleine's records due to time pressures, and one nurse involved in their care said she was 'learning on the job' when it came to treating mental health patients. 

Mr Stewart highlighted failures of staff not understanding Madeleine's risks including ongoing failures to conduct risk assessments, as well as failures to ensure relevant information was communicated to all staff involved in their care.

He said the lack of appropriate resources in terms of a bed in a mental health unit at the time may also have contributed to Madeleine's death, although he found the East of England Partnership Collaborative who manage bed allocation did everything they could at the time.

Madeleine had been on the ward for 12 days before the attempt on their own life, and the average wait for a mental health bed in February 2022 was around 46 days.

Following the hearing, A statement on behalf of Madeleine's parents was read outside the coroner's court.

Amanda Cavanagh, from Ashtons Legal, read a statement on behalf of the family outside Suffolk Coroner's Court. (Image: Newsquest)

Amanda Cavanagh, an associate at Ashtons Legal, said: "Our family are heartbroken and devastated by the loss of Madie and need time to consider the conclusions of the Coroner today.

"The inquest has been particularly distressing as we heard how Madie was trusted into the care of Ipswich Hospital to a ward with an amateurish and incompetent approach to mental health, safeguarding and risk. 

"Hearing both NSFT and ESNEFT argue amongst themselves as to who was responsible for Madie's care and who should have responded to the direct warnings only added further insult to significant injury. 

"Madie was our daughter and her death was entirely foreseeable and preventable." 

A Prevention of Future Deaths hearing will now be scheduled.