Teen reported missing 10 times before her death
Coroner has serious concerns over her treatment
A CORONER is writing to the Ministry of Health raising serious concerns over the death of a teenager who “fell through the cracks in the system”.
Coroner Lydia Brown said she had a number of serious concerns about how Leicestershire Partnership NHS Trust treated Victoria Halliday in the months before her death.
She criticised the quality of the community mental care services in Leicestershire and the refusal of the trust to act on the views of her family doctor and her personal counsellor.
Mrs Brown said that in a bid to prevent future deaths, she was writing to the Ministry of Health, the Chief Coroner, the chief executive of the trust and the local Clinical Commissioning Group
Mrs Brown is also writing to the Department of Health concerning the absence of psychiatric intensive care beds for women in Leicestershire.
She said: “This is not an issue here but nationally.”
The 19-year-old was found hanged in a wood near her home on July 30 last year after going missing 10 times.
The four day hearing at Leicester Town Hall heard Victoria, from Broughton Astley, had told mental health staff she heard voices telling her to complete a mission.
She said she had superpowers and could climb anything.
She was recovered from the top of the Haymarket car park and a cine- ma complex in Milton Keynes.
Doctors at the Bradgate Unit discounted suggestions that she was suffering from psychosis saying the delusions were part of her personality disorder.
Mrs Brown said if the trust had examined Victoria’s journals deeply they would have seen signs of psychosis.
Independent psychiatrists said in patient care should have been considered.
However there are no psychiatric intensive care beds for women in Leicestershire.
Mrs Brown dismissed both a suicide or misadventure conclusion because she could not be certain that Victoria realised what she was doing.
Recording a narrative conclusion she said: “Vicky’s mental health started to deteriorate in the early part of 2015 following a year of stability.
“She was sectioned under the Mental Health Act and admitted for impatient care in the Bradgate Unit, Leicester for diagnosis and treatment.
“She was diagnosed with emotionally unstable personality disorder.
“The plan was to care for Vicky in the community with expected ongoing brief admissions in times of crisis.
“During June and July 2015 Vicki repeatedly presented in crisis.
“Numerous missing person reports required police involvement across various geographical locations and she was brought back for psychiatric assessment in Leicester due to concerns for her and the public’s safety.
“On each occasion she was discharged back into the community.
“There was no effective or robust community support.
“Ample evidence was available to suggest that Vicky was starting to experience psychotic symptoms from May onwards.
“But opportunities were missed to fully and adequately explore these and reconsider the necessity for in-patient care.
“On July 29 the final missing person search was com- menced. Vicky was discovered to have taken her own life, but her intent could not be established given the well-documented bizarre thought processes she had been experiencing.”
She dismissed statements by employees of the Leicestershire Partnership Trust concerning the alleged “secretive nature” of dad Nigel concerning the employment of the counsellor.
Mrs Brown said: “I find as a matter of fact that Vicky’s father was perfectly open and did all he could to safeguard and protect his daughter.”
She also believed counsellor Janet Bagley, who broke professional confidentiality and rang the Bradgate Unit voicing her concerns and received a reply the next day.
This call was denied by the Trust.
She praised the dedication and professionalism of the Leicestershire Police missing persons team in their repeated work in trying to safeguard Victoria.
Finally Mrs Brown gave her condolences to Mr Halliday.
She said Victoria “fell through the cracks in the system” and the family were left to “pay the ultimate price for the lack of appropriate care”.
Victoria fell through the cracks in the system and the family were left to pay the ultimate price for the lack of appropriate care Coroner