Mary Jane BUSH · Prevention of Future Deaths report

On 17/08/2020 I commenced an investigation into the death of Mary Jane BUSH aged 15. The investigation concluded at the end of the inquest on 19/10/2021. The medical cause of death was:
1a) ████████
1b)
1c)
2
The conclusion of the inquest was: Suicide.

Mary Bush had a diagnosis of anxiety disorder, post-traumatic stress syndrome and suicidal ideation. She was referred to the mental health team in November 2019 and was assessed in January 2020. Mary Bush was awaiting referral for psychological therapy at the time of her death. On 6 August 2020 Mary was found ████████ to her home. Evidence was heard that Mary had intended to take her own life by her actions

1. Mary was referred to the mental health team in November 2019 and was assessed in January 2020, some three weeks later than should have been.
2. There was a delay in Mary receiving psychological therapy. She was still on the waiting list at the time of her death.
3. The evidence was that at the date of inquest, there continued to be a delay in service users receiving psychological therapy. Evidence was heard that balancing capacity and demand, which has increased, remains a challenge. The cases referred are of increasing complexity, as in Mary’s case
4. Some steps have been taken in an effort to deal with this, such as specific risk assessment training, focusing on intervention treatment plans to aid capacity and throughput, reviewing the skill mix of staff
5. However, there is the ongoing issue of recruitment and retention of suitably skilled staff by the Trust and the ability to resource this to enable the Trust to function effectively