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Inquest Concludes Neglect Contributed To Death Of 17-Year-Old Girl Who Was Allowed Out Of Mental Health Unit

NHS Admits Faults After Specialist Medical Negligence Lawyers Investigate Her Care


The devastated family of a 17-year-old girl who died when she was able to leave a mental health unit and was struck by a train have spoken out for the first time after a Coroner concluded her death was contributed to by neglect and the NHS Trust responsible for her care admitted it was at fault.

Alice Gibbs from Barnet in North London died on 14 October 2013 from multiple injuries after being hit by a train at Mill Hill Broadway Station. Alice was meant to be on one-to-one observations at arm’s length by staff at The Beacon Centre Mental Health Unit in Edgware, meaning that she would not have been able to leave the Unit without the input of the MDT [multi-disciplinary team] However, her one to one observation level was downgraded and she was able to walk out of the front door.

Her parents instructed specialist medical negligence lawyers at Irwin Mitchell to investigate the care she received at the mental health unit. An inquest concluded neglect played a part in her death and the NHS Trust responsible has admitted they were at fault.

At a three-day inquest into her death at North London Coroner’s Court last month, HM Coroner Andrew Walker recorded a narrative conclusion that her death was contributed to by neglect.

He said: “There was a serious failure not to ensure that the MDT [multi-disciplinary team] meeting on the day of Miss Gibbs’ death knew of the concerns about a change in her mental health state. Had this change in her mental state been known it is likely that her observations would not have been changed from one-to-one observations which would have prevented her from leaving the Unit. In this respect her death was contributed to by neglect.”

He also said the changes in Alice’s mental state were evident from the notes that Alice had written. It emerged from the Inquest that a note revealing her state of mind written by Alice had been passed to Daniel Keith, the Ward Manager. This was hours before Alice was allowed to leave the unit, but this was not disclosed to the MDT meeting. The Coroner also highlighted that the family had raised concerns about Alice’s state of mind.

At the inquest Abigail Anorjin, Charge Nurse at the Beacon Centre, denied Mr Gibbs had warned her that Alice was intending to leave the unit to take her own life. The Coroner said he accepted entirely Mr Gibbs account of the conversation.

The 17-year-old had a history of mental health issues and was admitted to the Beacon Centre Mental Health Unit after her parents became concerned about the risk she posed to herself and her deteriorating mental health.

Before she was allowed to leave the unit Alice repeatedly told care workers and her parents that she wanted to leave the facility and therefore should have been closely monitored by staff. Prior to her stay at the Beacon Centre Alice had numerous visits to mental health services which also left her family disheartened as to whether she was receiving the best care available.

Matthew Bebb, a specialist medical negligence lawyer at Irwin Mitchell’s London office, representing the family, said: “Alice’s family have been left absolutely devastated by her death. This is a very difficult time for them and whilst the inquest has gone some way in providing answers to the many questions they had, they remain concerned about the care she received before she died and want reassurance that improvements will be made.

“I would like to thank the Coroner for conducting a very thorough investigation into the circumstances surrounding of Alice’s death and concluding that her death was contributed to by neglect. 

“It is now vital that lessons are learned to ensure that vulnerable young people are provided with the appropriate level of care and observation and in the correct environment for their needs, in order to prevent these types of tragedies occurring in the future.”

Her mother said: “The impact of Alice’s death on our family has been enormous; we have struggled to come to terms with what has happened.

“I have developed a general mistrust of the mental health services as a result of Alice’s death and the way she was severely let down by the medical professionals that we entrusted to care for her.

“Alice was a child in crisis and I feel that there was a year of wasted opportunities in the mental health service, followed by the final failures at the Beacon Centre to care for her and keep her safe.”

If you or a loved one has suffered as a result of mental health negligence, we may be able to help you claim compensation. See our Medical Negligence Guide for more information.

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