Care of Grantham teenager Evelyn Gibson explored at inquest
Questions have been raised about the discharges of a teenage girl from specialist mental health wards in the months before she died.
The inquest into the death of 15-year-old Grantham girl Evelyn Gibson, who died on April 15, 2022, opened at the Myle Cross Centre in Lincoln on Monday.
During the inquest, health professionals have defended a number of decisions, particularly around discharges from the Beacon Hospital in Leicestershire in December 2021 and March 2022.
Evelyn was released from section in late December but, days after a December 16 meeting with health professionals, she self-harmed multiple times across several days, leading to hospital stays and readmission to the Beacon ward on December 23.
A few weeks later, she was then being prepared for a further discharge in March.
Questions were raised about the timeline in the run-up to the discharge in December, Evelyn’s ability to mask issues, and her repeated self-harm, including one incident where she became unconscious.
Weeks before this discharge, doctors had been considering placing her in a paediatric intensive care unit but felt she had made improvements following a series of interventions, including the application of 2:1 staffing overnight.
A major concern for Evelyn’s family is that, despite Evelyn previously having 2:1 night-time staffing at the Beacon (later reduced to 1:1) and recognition that her worst struggles occurred from 7pm onwards when left alone, a recommended 7pm to 9pm professional support was never implemented.
A Section 117 plan, which outlined Evelyn’s aftercare, included this professional support, but it was not implemented for her December or March discharges.
Concerns were raised about whether the impact and increased pressure on Evelyn’s parents had been considered.
The out-of-hours phone line for CAMHS - the mental health service - closed at 7pm.
Alex Longmore, clinical lead at CAMHS, had oversight of Evelyn’s care from September 2021.
He felt enough measures had been put in place before her discharges, including the provision of education, counselling, and other support.
He told the inquest that prior to her December release: “I felt we had a relatively good understanding of what might be required and what the Community Crisis Enhanced Treatment Team (CCET) might offer."
Before the March discharge, he said: “CAMHS had highlighted there was an intervention needed at that time (7pm to 9pm), but we didn’t see it as a barrier to discharge.”
He told the inquest on Wednesday that interventions were working towards improvements.
Other issues included staff changes disrupting Evelyn’s need for consistency, her parents having to transport her to the Beacon Hospital after self-harming in December, and the use of ineffective medicines.
Dr Abhay Rathore, consultant psychiatrist at Beacon, said: “Yes, things did not go well at that time, but that does not mean that careful thought had not been put into the planning process.”
He repeatedly told the inquest he believed Evelyn’s assessments and actions were balanced with concerns and that community discharges could benefit patients.
He said that discharge was not necessarily the end of a journey but a next step, and that gradual reintroduction to communities was an aim to improve health.
The inquest noted Evelyn’s triggers included guilt over receiving help and feeling unworthy when treatments failed.
A social worker told the inquest that not enough time had been given to create the Section 117 plan.
Rebecca Headington, Evelyn’s social worker based at Lincolnshire County Council, said aftercare plans usually needed about three months to develop.
She said this allowed social workers, who were sometimes coming in fresh, to carry out full investigations as well as get to know the young person and their family.
The referral was created on December 6, and Rebecca was allocated on December 8.
“That’s quite a short period of time,” she said, with the inquest hearing that she had emailed her concerns to all parties at the time.
“We were coming into that new.”
She said part of her concern was whether there was enough understanding of the situation, with worries Evelyn might be disappointed if her festive experience was not “Chocolate Box Christmas” perfect.
The responsibility for completing a Section 117 plan was multi-agency, she said, with it mostly being put together by her and Sarah Millott.
It was noted that there had been a lack of clarity about who was responsible for taking things forward, leading to confusion over the 7pm to 9pm provision.
An email to the ICB from Rebecca, which included CAMHS representatives, was not followed up on. Rebecca expressed regret over not pursuing it further.
“It should have been for the local authority and ICB to complete,” she said.
“I should have flagged it more,” she added, breaking into tears.
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.
Weight gain was also a trigger, with CAMHS child clinical psychologist Joanna Darby relating a story where Evelyn had gained 1kg and reported an increase in self-harm.
The inquest heard that mental health and eating disorders are not linear in their treatment.
The impact of Covid-19 was also explored, with several meetings conducted virtually rather than face-to-face.
The headteacher of KGGS has admitted regretting some decisions about Evelyn’s time at school, adding changes have since been made.
James Fuller told the inquest on Tuesday that adjustments were made to support Evelyn in the classroom, including letting her parents join her at lunch, seating her near trusted friends, arranging one-to-one tutor support, and allowing subject changes, such as from food tech to German, to avoid mental health triggers.
However, he admitted making an 'incorrect decision' by not allowing Evelyn access to online learning after Covid, explaining he should have ignored government advice restricting it to students with Covid or in isolation, as Evelyn was in hospital.
Mr Fuller was also questioned about a decision to send Evelyn home.
Mr Fuller said the decision was made in a bid to protect her and that he had considered a number of factors, including whether he could “guarantee her safety in school.”
“At the time, I had a student whose mental health was worsening… I had a student where her mental health was overwhelming, her eating disorder had relapsed, and there was a crisis team involved,” he said.
“These factors contributed to my decision,” he added, saying he felt at the time that she would be safer at home with her family.
“At the time, I certainly didn’t think things would escalate by her not being in school.”
But Evelyn’s parents said Evelyn found reassurance in the structure of school and often felt most protected there, where she was distracted from her thoughts.
Mr Fuller said changes since April 2022 included increasing school counsellors from one to 2.5 full-time equivalents, training 14 staff as 'mental health first aiders,' creating a 'wellbeing board,' and sending mindful activities to pupils and parents. PSHE classes were also updated to include mental health topics.
“I do feel we’ve learned from such a tragic situation,” he told the inquest.
“We want to try and do everything we can to support our students.”
Evelyn’s parents also raised concerns about decisions around the removal of items, such as anxiety bracelets, which Evelyn used to stop herself from scratching.
The impact of the Covid lockdown highlighted how bad Evelyn’s mental health had become when she was admitted to the Rainforest Ward.
Government restrictions encouraged treatment away from inpatient units to curb virus spread.
Eventually, it was acknowledged that Evelyn needed to spend time on a ward for her physical health.
However, the virus also affected other areas. Ward rounds and meetings were held virtually, and confusion over the rules meant Evelyn fell behind on some of her schoolwork.
It was noted that this may have impacted her mental health as she lost structure, struggled to control her education, and suffered from comparing herself to classmates who were further ahead.
The inquest continues.
Locally there is also anew NHS 111 Emergency Mental Health Support line (dial 111 24hrs a day) links directly with our 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.
