Lincoln coroner details failings in Grantham teenager Evelyn Gibson’s mental health care
An inquest has found that a series of missed opportunities contributed to the death of a teenager with mental health problems.
Evelyn Gibson, 15, died on April 15, 2022, following her discharge from a mental health facility in Leicester weeks earlier.
The inquest, held at the Myle Cross Centre, concluded today (Monday, November 25), with area coroner Jayne Wilkes identifying a series of issues in Evelyn’s care, including delays in her original diagnosis and incomplete discharge planning from a Leicester mental health ward.
Delays in her initial diagnosis arose when health bodies first referred her for mental health support instead of treating her eating disorder—an issue only rectified through intervention by her health advocates, core CAMHS practitioner Sarah Millott and child clinical psychologist Dr Joanna Darby, both from Lincolnshire Partnership NHS Foundation Trust.
“This was part of Evelyn’s learning that she assessed her self-worth against the level of care she was receiving,” said Ms Wilkes.
Evelyn experienced a downward spiral, including health issues related to her reluctance to eat and excessive exercise. A 36-hour period during which she refused to eat or drink led to her admission to the Rainforest Ward in Lincoln.
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Her stay, from January 29 to April 12, 2021, included the use of a nasogastric tube due to her continued refusal to eat.
“Whilst over time her weight did improve, this resulted in a downward spiral in her mental health,” said Ms Wilkes.
Ms Wilkes highlighted that, despite staff being highly praised, some lacked understanding of how seemingly “positive comments”, such as praising weight gain or discussing their own weight struggles, could harm Evelyn’s mental health.
When discharged, Evelyn was medically fit but still “seriously unwell” said the coroner.
Her mental health continued to deteriorate. Following an incident where she was sent home from school on July 5, 2021, there were two incidents of self-harm requiring hospital treatment.
Ms Wilkes said Evelyn’s increasing self-harm and suicidal ideation in the following months painted “a horrendous picture of her life at this time”. Police were sometimes called to restrain her.
In July, she was admitted to Beacon Hospital, run by Leicestershire Partnership NHS Trust. At one point, she was considered for transfer to a paediatric intensive care unit (PICU), but her condition improved after a 2:1 overnight watch was implemented.
In November, Evelyn expressed a wish to be discharged for Christmas, and the process began shortly after.
The inquest heard how Evelyn had a “high expectation” of what Christmas might be like. Her parents, Jenni and Jack Swift, described the discharge process as “intensive”.
Unclear communication by the hospital led Evelyn to believe she was unwelcome at home, causing a breakdown in trust. Further concerns raised by her parents in relation to her rushed discharge plan were perceived by Evelyn as rejection.
Plans for an aftercare package, known as a Section 117 plan, were not in place when Evelyn was discharged. This plan required out-of-hours care from 7–9pm, which was not provided at the time and would require funding.
The inquest heard that Lincolnshire County Council was only consulted on December 6, with their representative stating that at least three months would be needed to arrange the necessary provisions.
A Lincolnshire Integrated Care Board member later testified that a panel might have been convened quickly, but they were only notified in February during planning for Evelyn’s second discharge.
Uncertainty over who was responsible for organising the aftercare plan meant it was never implemented.
“The reality at this point was that there was insufficient planning,” said Ms Wilkes.
She added that there were “enormous and significant” issues with Evelyn’s care before her discharge.
Evelyn harmed herself several times after her discharge, resulting in hospital stays. In one instance, she ran away from her mother during a ward round call and had to be restrained and returned by a hospital security guard before reaching a dangerous main road.
She was readmitted to Beacon Hospital shortly after, but her parents were initially told they would have to transport her in their own vehicle. Although they were later asked to collect her, it was eventually agreed that she would be readmitted—initially voluntarily but later under Section 3 which is involuntary.
Ms Wilkes said this led to a further downward spiral as Evelyn lost much of the progress she had made.
“It is not difficult to see how she would have perceived this as her own failure,” she said.
Despite this, doctors were shortly after back on getting her discharged again, this time by the end of end of February.
Doctors resumed plans for her discharge by the end of February, weighing up the risks of her remaining in hospital against those of care in the community. They noted concerns about institutionalisation.
Again, issues arose with the Section 117 plan. Despite a request for funding, no progress had been made due to missing information.
The support was still not in place when Evelyn died.
“This support was never put in place,” said Ms Wilkes.
Before her discharge, incidents of self-harm—including one that left her unconscious and requiring treatment at Leicester Royal Infirmary—were treated as isolated cases. Doctors maintained that community care was the best option.
Although Evelyn showed some improvement, she continued to suffer from mental health problems, including hallucinations and triggered reactions to specific locations and events.
A holiday in Northumberland brought some respite, despite some minor self-harming, with Evelyn reportedly appearing happier, almost like her old self. However, she visibly changed on their return.
The night before she died, she had a sleepover with a friend she trusted and appeared happy and positive.
The following day, sometime between 3.30pm and 4pm during 30-minute checks, Evelyn left the house, leaving her phone behind.
Her body was later found by a dog walker. The medical cause of her death, a month before her 16th birthday, was ligature compression of the neck.
Ms Wilkes concluded that Evelyn had died by suicide, based on CCTV evidence of her actions.
She noted that Evelyn felt she was not worthy of help and judged how much she was cared for by the level of treatment she received. She would self harm when she could not control her emotions and set herself high expectations. She also struggled with guilt when she reflected on having a positive day.
Ms Wilkes also found multiple failings in Evelyn’s care, particularly around her discharge, which she said “did not come in a timely manner”.
“I’m satisfied that the state was responsible in part for this and this was a real and significant risk to her life,” she said.
“She was not OK. She was on 30 minute watches. She had to be observed. Her mother had to monitor her,” said Ms Wilkes.
“This did not place an unreasonable or disproportionate responsibility on the state.”
Ms Wilkes also noted “a lack of consideration for the significant concerns raised by Evelyn’s family throughout the discharge process”.
However, although lessons were learned, she found no causative link between Evelyn’s death and the actions of Lincolnshire County Council or Kesteven and Grantham Girls' School.
In the case of the school, Ms Wilkes said: “ I am satisfied that what happened afterwards could not have been foreseen by the school and I’m satisfied that the treatment by the school in no way fell below the known and recognised standards.”
Ms Wilkes acknowledged improvements made since Evelyn’s death, including increased mental health staffing and enhanced PSHE curriculums.
She also recognised that a number of improvements to health services had taken place since Evelyn’s death, and so did not make any further orders for improvement.
Ms Wilkes praised Evelyn’s mum Jenni for her work with the health bodies to improve what was on offer.
The inquest was told of major changes which had taken place following Evelyn’s death and the subsequent reviews.
Eve Baird, chief operating officer at Lincolnshire Partnership NHS Trust (LPFT), told the inquest that nearly £1.2million has been invested in Core CAMHS, eating disorder services, and learning disabilities support, helping to reduce waiting times.
Improvements include staff training on Section 117 to address gaps in understanding, and the establishment of 24/7 mental health professionals at Boston and Lincoln hospitals. These professionals work in emergency departments and support young people admitted to acute medical wards.
A mental health urgent assessment centre has also been created on the Lincoln County Hospital site, providing support for individuals experiencing a mental health crisis without a physical healthcare need. This service can be accessed without referral, offering a safe alternative to attending A and E.
Additionally, the number of school mental health support teams across the county is expanding as national funding becomes available.
“Our thoughts continue to be with Evelyn’s family at this sad time,” said Eve, after the inquest’s conclusion.
“We were saddened that the coroner concluded that elements of Evelyn’s care fell below the standards we would hope for our families.
“We remain committed to delivering the very best care to children, young people and their families when they struggle with their mental health and wellbeing.
“We have worked very closely with Evelyn’s family to understand their experiences, completed a thorough review and made changes in response to learning we have taken from Evelyn’s tragic death.
“As part of a wider transformation of services we are now working with local commissioners, children and families to co-produce the way services will be delivered in the future, and we continue to improve the information we provide to help people access the most appropriate support.
“We continue to be grateful to Evelyn’s family for working with us in such heartbreaking circumstances, to continue to improve the services we offer in the future.”
A Leicester Partnership Trust (LPT) Zayad Saumtally, head of nursing and quality, said there was now senior staff appointed to maintain two-way communication with families upon admission, addressing ongoing concerns.
The trust had also strengthened discharge processes and updated Standard Operating Guidance (SOG) to improve service delivery, including discharge checklists created and updated during each ward round to ensure consistency, improved connections between local teams and decision-makers and allocated staff to discuss concerns before ward rounds and facilitate communication.
A statement from Leicestershire Partnership NHS Trust said: “We offer our sincerest condolences to Evelyn’s family and friends for their loss. We are committed to providing the best quality care for our patients and to being a continuously learning and improving organisation.
“We undertook an internal investigation to highlight any learning from this tragic event and to ensure that our services meet the highest standards of care that our young people deserve.”
Locally there is also a new NHS 111 Emergency Mental Health Support line (dial 111 24hrs a day) providing links directly with local crisis teams.
And the Lincolnshire Here4You advice line on 0800 234 6342 (open 24/7) for anyone seeking emotional wellbeing and mental health support for children and young people, it is open to parents too for help and advice.
