A 15-year-old who passed away in the hospital after attempting suicide had waited two weeks for a bed on a mental health unit, according to the findings of an inquest.
On February 3, 2022, Madeleine Savory self-harmed and was subsequently admitted to Ipswich Hospital.
A bed was not located before their death, despite ramping up the bed request after staff raised safety concerns.
The NHS East of England region had 19 young people waiting for beds in February 2022, the court was informed.
Madeleine's family said they were "overwhelmed with grief and anger" in a statement as the inquest got underway on Monday.
After being referred to mental health services following a hospital admission in September 2021, Madeleine—who used they/them pronouns—had been under the care of Norfolk andamp; Suffolk NHS Foundation Trust (NSFT).
On October 21, when they were evaluated, it was discovered that they had gender dysphoria, anxiety, low mood, and food restriction.
According to testimony given at Suffolk Coroner's Court, they committed self-harm on several occasions between September and February, which caused their family to grow increasingly concerned about their risk.
They had self-harmed on February 3 after leaving Ipswich's Northgate High School, but the institution hadn't alerted anyone about them for more than an hour, according to information provided to the inquest.
On February 7, they were hospitalized and added to a waiting list for a bed in a mental health unit.
On February 19, as they waited for a bed, they attempted suicide. They passed away a week later, according to the inquest, which started on Monday.
When trying to secure "tier 4" beds for young people due to bed availability in the area, Emma Ellis, who served as the community team leader for East Suffolk's children and young team at NSFT, said she was "frustrated.".
It had gotten harder, she claimed, because of bed closures and the pandemic.
After ward staff expressed concerns that they would be unable to keep Madeleine safe after discovering items they had hidden that could be used for self-harm, the bed application was revised on February 14.
The mental health team suggested adding staff and funding for risk management.
"So here we are again, another person waiting for a tier 4 bed," Ms. Ellis wrote in an email to the ward offering support.
Coroner Darren Stewart enquired from her regarding the frequency of this issue.
She retorted that in her opinion, it was a "significant problem," particularly in light of the pandemic.
The investigation is ongoing.
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