Staff failed to look into the teen's history of self-harm, according to the Madeleine Savory inquest

Outside of Ipswich Hospital

An inquest found that the hospital staff caring for a 15-year-old who died after attempting to take their own life were too busy to thoroughly review the patient's records.

In February 2022, Madeleine Savory passed away at Ipswich Hospital.

On February 19, while they were waiting for a bed, Madeleine attempted suicide and died a week later.

The coroner's court was informed by consultant pediatrician Dr. Mariette Fernando that staff members were not fully informed of the patient's unique risks of self-harm.

Madeleine was cared for by the Norfolk andamp; Suffolk NHS Foundation Trust (NSFT) after being referred to mental health services as a result of a hospital admission in September 2021. Madeleine used the pronouns they/them.

On October 21, when they were evaluated, gender dysphoria, anxiety, a depressed attitude, and food restriction were discovered.

The inquest in Ipswich heard that they had several instances of self-harm between September and February.

On February 7, they were admitted to the hospital and put on a waiting list for a bed in the mental health unit.

While they waited for another bed to become available, they were on a ward.

Due to time constraints, according to Dr. Fernando, doctors on the ward did not routinely review the medical records of newly admitted patients, so ward staff was unaware of any potential increased risks.

She added that "both sides were making assumptions of the other side," but she "would have hoped that the mental health team would have alerted us to those factors.".

Time constraints, according to Dr. Fernando, still existed, but more staff members now reviewed records and informed doctors.

The investigation goes on.

Help is available through the if the problems in this story are affecting you. Action Line at BBC.

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