Grieving parents of Grantham teenager Evelyn Gibson react after inquest highlights failures in her mental health care

The family of a teenager who died following mental health problems say they have been vindicated by the results of an inquest into her death.

Evelyn Gibson, 15, of Grantham, died on April 15, 2022, following her discharge from a mental health facility in Leicester weeks earlier.

At the conclusion of Evelyn’s inquest at the Myle Cross Centre on Monday, coroner Jayne Wilkes highlighted issues in Evelyn’s care, including delays in diagnosis and incomplete discharge planning.

Following the conclusion, Evelyn’s mother and stepfather, Jenni and Jack Swift said Evelyn was “incredibly loved” and “profoundly missed”.

“She made us proud every single day and continues to do so,” they said in a statement.

“Evelyn left this world far too soon, creating an indelible void, but we will be eternally grateful to have had the joy of her in our lives.”

The Samaritans offer a free 24/7 helpline at 116 123, providing round-the-clock support. You can also reach them by email at jo@samaritans.org or visit samaritans.org for local branch details.

Jack and Jenni said they were grateful to Ms Wilkes for a thorough, detailed, and compassionate investigation, as well as the witnesses who had given evidence.

“As anyone can imagine, reliving our daughter’s death, and the traumatic years leading to her death, has been very difficult, and we have been grateful for the sensitivity and dignity we have been treated with.

“While we have been taken back to some devastating events, we have also been reminded of the input of some remarkable and dedicated professionals involved in Evelyn’s care.”

The conclusion was that Evelyn died by suicide, with Ms Wilkes highlighting a lack of clear and appropriate discharge planning.

“This vindicates the struggle we had over the lengthy time of Evelyn’s inpatient treatment, where our concerns were repeatedly dismissed. It shouldn’t have taken Evelyn’s death for our voices to be heard,” said Mr and Mrs Swift.

Other issues included missed opportunities in Evelyn’s early care and poor language use for young people with mental health or eating disorders.

Ms Wilkes found that Article 2 was engaged in respect of Evelyn’s care by Lincolnshire Partnership NHS Foundation Trust and Leicester Partnership NHS Trust, particularly around her discharge, which she said “did not come in a timely manner”.

Article 2 inquests address cases where the state failed to act on known risks.

The evidence showed that Evelyn was discharged from inpatient care at the Beacon hospital in March 2022 because the ward environment was no longer considered safe for her.

Staff told the inquest they balanced risks of institutionalisation with community care.

However, evidence showed Evelyn remained at exceptional risk.

Ms Wilkes told the inquest: “I’m satisfied that the state was responsible in part for this, and this was a real and significant risk to her life.

“She was not OK. She was on 30-minute watches. She had to be observed. Her mother had to monitor her.”

“This did not place an unreasonable or disproportionate responsibility on the state,” she added.

The coroner found that Evelyn did not receive the aftercare she was assessed as needing under the Mental Health Act 1983.

The trusts both admitted aftercare shortcomings but noted improvements, including enhanced crisis support for children.

Evelyn’s own words were read out by the coroner during her summary, taken from an English assignment Evelyn wrote in 2021.

In it, she said: “I can’t help but wonder if I was first diagnosed and given the help when I first reached out, would things be different now?

“Would I still have spent so long in hospital? Would I have got to the point where people were worried for my life? Would things still have been the same?”

Jenni and Jack said it was “sadly too late” for Evelyn but hoped the new changes to mental health services would prove beneficial for other young people and their families.

The coroner’s investigation included the first-ever request to Ofcom under the Online Safety Act 2024, which took effect on April 1, 2024, seeking social media material related to a child’s death.

While no specific trigger for Evelyn’s death was found, this outcome reassured both the coroner and her family.

“We were privileged to have Evelyn in our life for nearly 16 years and continue to spread her kindness through #evelynsbutterflyeffect, which was set up in her memory and encourages everyone to spread kindness through their actions towards others,” said Jenni and Jack.

They expressed gratitude to the charities and organisations that had supported them, including Parenting Mental Health, Beat (Eating Disorders), Young Minds, CALM, Survivors of Bereavement by Suicide (SOBS), and Amparo.

“Evelyn said she didn’t want others to go through what she went through, and moving forward, we will continue to advocate for young people struggling with their mental health, for the improvement of services, and continue being a voice for our beautiful Evelyn,” said her parents.

Jenni and Jack Swift were represented by Charlotte Andrews of Simpson Millar Solicitors, instructing Harriet Short of One Pump Court Chambers.

Charlotte said: “Evelyn’s family tirelessly advocated for their daughter during her care and continue to do so today.

“The coroner’s investigation has allowed their voice, and Evelyn’s, to be heard, and the findings today bring some relief as they continue to come to terms with their loss.”

The coroner noted that no Regulation 28 report was issued to prevent future deaths due to the policy developments made after Evelyn’s death.

Trust representatives acknowledged the significant contributions of Jenni, whose efforts, along with Jack, also led to policy changes at Kesteven and Grantham Girls’ School.

Local contacts include a new NHS 111 Emergency Mental Health Support line (dial 111 24hrs a day) providing links 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.