“(brief summary of matters of concern) Evidence received at Inquest included NICE…”

The coroner’s concerns

(brief summary of matters of concern) Evidence received at Inquest included NICE guideline [NG225]; 'Self-harm: Assessment, Management and Preventing Recurrence.' Published: 07 September 2022. This guidance states inter alia that: "Following triage, patients who have self-harmed should receive the requisite treatment for their physical condition, undergo risk and full psychosocial needs assessment and mental state examination, and referral for further treatment and care as necessary” and “All people who have self-harmed should be offered an assessment of needs, which should be comprehensive and include evaluation of the social, psychological and motivational factors specific to the act of self-harm, current suicidal intent and hopelessness, as well as a full mental health and social needs assessment.” Evidence was also received in the form of a Joint Policy Document published by Suffolk and North East Essex Integrated Care Board (SNEE) and Suffolk County Council (SCC) (Version 21 – January 2023) titled ‘Suffolk and North East Essex Health & Social Care Protocol for the Support of Children and Young People in Crisis.’ This Policy document outlined the resources available in circumstances where Young People Present into an Emergency Department (ED) in Suffolk to facilitate NICE recommended urgent and emergency care, including NICE recommended treatment for self-harm. The available resources on a 24/7 basis for all age groups includes the Mental Health Liaison Regulation 28 – After Inquest Document Template Updated 30/07/2021 Service (MHLS) which offers specialist mental health care in a physical health setting by supporting the work of clinicians working in general health pathways, enabling EDs and wards in general hospitals to assess and support mental health needs as they present or arise among people being cared for in the general health pathway. Evidence received during the course of the Inquest indicated that neither the NICE Guidance nor the SNEE/SCC Policy were applied in relation to the care and treatment extended to Erin in the West Suffolk Hospital Emergency Department during her attendance over the period 31st December 2022 to 1st January 2023. The failure to apply this guidance/policy meant that there was a missed opportunity for mental health services to engage early with a vulnerable child who had presented to the Emergency Department having undertaken an act which she described as an overdose.

An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.

Source

judiciary.uk, Prevention of Future Deaths reports, 2024-0636

Added to Minute Book

8 Oct 2026

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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0