‘Prevention Of Future Deaths Order’ Issued Following ‘Catalogue Of Missed Opportunities’
A teenager with mental health problems died following a “catalogue of missed opportunities” to treat her illness, a coroner has ruled.
Afrika Yearwood, 18, ‘fell between the cracks’ of mental health services in the city when she was not referred for treatment for six weeks.
She died in Leeds General Infirmary just weeks after her 18th birthday. Four days previously she had been found hurt at the family home in Rothwell.
Following her death, Afrika’s mum Beverley, instructed expert medical negligence lawyers at Irwin Mitchell to investigate her care and support the family through the inquest.
Senior coroner, Kevin McLoughlin, has now issued a ‘prevention of future deaths order’ demanding Leeds Community Healthcare NHS Trust and Leeds and York Partnership NHS Foundation Trust state how they intend to improve services to reduce the risk of a similar incident happening.
It comes after a previous internal NHS report had also identified ‘failings’ in the lead up to Afrika’s death.
Expert Opinion“The internal NHS investigations conducted following her death and subsequent inquest have highlighted that more should have been done to help Afrika.
“Young people who are known to mental health services falling between the cracks is a growing concern. Afrika’s death is a stark reminder of what can happen when people do not receive the support they need.
“While nothing will make up for the anguish and pain her family continue to face, it is vital that lessons are learned from Afrika’s case to improve patient care.
“We will continue to support Beverley at this incredibly difficult time to help her try to come to terms with what has happened the best she can.” Lauren Bullock - Solicitor
Afrika, who was studying for her A Levels, had been seeing a private therapist since December 2017.
She underwent a NHS assessment on7 March, 2018. However, Wakefield Coroner’s Court was told that the Child and Adolescent Mental Health Service ‘transitions’ team in Leeds never received an email. This meant Afrika was not formally referred to the service which would move her on to adult mental health services when she turned 18, nor was she referred to her GP.
Afrika was referred back to mental health services in May and underwent consultations on May 3 and 17.
During her assessment on 17 May she stated that she was struggling to cope and may do something soon. She was referred to the adult services that day. However, her appointment was for 31 days times.
Afrika died on 25 May.
Mr McLoughlin recorded a narrative verdict in which he said Afrika was never diagnosed and that there were a “catalogue of missed opportunities” to help her.
The coroner urged the agencies involved to reconsider their systems so there are fail safes if contact with the young person is overlooked.
Mr McLoughlin added that although it was possible that other services could have prevented her death. He was unable to say on the balance of probabilities that it would have prevented it.
However he issued a Regulation 28 ‘prevention of future deaths order’ because he deemed there were still risks that young people could “fall between the stools”.
Beverley said: “Afrika was the most beautiful, affectionate and caring daughter any mum could ever wish for. She had a smile that would light up the room.
“Our family will never fully get over losing her in the way we did. It’s heart-breaking to know she will never get to fulfil the dreams and ambitions she had in life and we will never get to see her achieve milestones in life such as going to university, getting her first job or getting married.
“I would like to thank the Coroner for listening to our voice and our concerns. We now feel that we been heard and we have some answers. The evidence that has been heard in my view has highlighted several human errors, multiple failings and missed opportunities and that national and local protocols were not followed.
“It is my opinion that working in a multi-disciplinary way is not a new concept but in Afrika’s case this did not happen due to a lack of communication between the various agencies involved.
“After the sad event of Afrika’s death, the first investigation conducted by the Leeds & York Partnership NHS Foundation Trust was found to be inadequate and as a result, the Leeds Community Healthcare Trust had to conduct a second more in-depth investigation to address the limitations of the first report.
“I am therefore pleased that the Coroner has concluded that a section 28 regulation order was required for both Trusts to ensure the safety of future young people approaching the age of 18 with mental health difficulties.
“I am determined to honour Afrika’s memory by campaigning for change in mental health services. If we can save one young person then possible Afrika’s death will not have been totally in vain.”
Talented student Afrika was in the process of completing her A-levels when she passed away aged 18 at Leeds General Infirmary towards the end of May 2018. Four days earlier she had been found injured at her family home.
A subsequent report by Leeds and York Partnership NHS Foundation Trust highlighted a series of failings in the support she received, including that referral pathways and national guidelines were not followed correctly.
It recommended that the Child and Adolescent Mental Health Service (CAMHS) in Leeds needs to review its pathway for those who are close to 18, while it was suggested that more efforts could have been made to ensure Afrika was seen by experts in a timely manner.
Afrika had been seeing a private therapist since December 2017 but had her first contact with mental health services in March 2018, one week before her 18th birthday. While she was seen by CAMHS for an assessment, the report into her care outlined how a summary letter was sent to her GP and her case was closed.
The report stated that the plan drawn by CAHMS following Afrika’s assessment in March was ‘ambiguous’ which ‘resulted in uncertainty of expectation of all involved.’ Ultimately, the report found that ‘it was not clear which, if any of the CAMHS pathways were being followed.’
In its conclusion the report highlighted the ‘lack of professional discussion’ between all the parties involved ‘led to insufficient gathering of information to make an informed clinical decision of what should and could have been the most appropriate care and intervention for Afrika at that time.’
In April, Afrika’s GP questioned why Afrika had not heard from either a transition or adult mental health worker. Seven weeks later after being transferred between services and receiving a four-minute triage assessment over the phone, a letter was sent to Afrika stating that she did not meet the criteria for adult mental health services.
Afrika was subsequently referred to a primary care mental health practitioner. Beverley continued to challenge the decisions made and questioned why no contact had been made with Afrika’s private therapist or her GP to ensure the right decisions about her care needs were being made.
Following Afrika’s comments to the NHS mental health professional, concerns were escalated to the Adults Community Mental Health Team. Afrika was given an appointment for 31 days later after her appointment with the NHS mental health professional.
This is despite the fact that Afrika should have been booked in for a ‘gatekeeping assessment’ which would have occurred much sooner than her scheduled appointment.
Since Afrika’s death, her friends and family have raised a total of £14,100 with the support of businesses and the local community for The Rothwell Cluster in her memory.
The Rothwell Cluster is a group of schools in the South Leeds area which offers an emotional and wellbeing counselling service for young people. The funds raised will reduce current waiting times and allow the Cluster to help an addition 25 young people access the counselling support they need.