A 12-year-old girl in crisis was sent to Sheffield for help. Three weeks later, she was dead

The task of an inquest is both simple and so complex as to be almost impossible. Someone has died and a coroner, or in rare cases (like this one) a jury, must establish how and why. The how may be fairly obvious, though it sometimes proves less so than it first appears, but the why is always difficult. Everyone must die at some point. The question an inquest asks is: in another universe, one where everything went as it should, could this particular death have been prevented?

It’s a vital question, since answering it may help to prevent similar tragedies in future. But no one at an inquest held in this universe can ever be a citizen of that other, more perfect world. As one witness, consultant psychiatrist Dr Danielle Lavelle, told the jury last week, when asked what she might have done differently: “This is a question I have asked myself more times than I can tell you. I honestly can’t answer that with any confidence, because I can’t un-know what I know.”

What Dr Lavelle knows now is that, by the early hours of 30 January 2024, 12-year-old Mia Maisie Lucas would be dead. It had been just three weeks since she arrived at the Becton Centre in Beighton, a specialist in-patient facility for young people with serious mental health problems and one of only six in the UK that receives patients under the age of 13. In those 20 days, there had already been four concerning incidents involving Mia, including one less than 24 hours before her death, which Dr Lavelle only learned about after the fifth incident that ended her life.

Over four gruelling days last week, Dr Lavelle and eight other people who looked after Mia at the Becton Centre were summoned to Sheffield’s coroners’ court, the Medico-Legal Centre, to answer questions. In front of a jury and Mia’s extended family, they were grilled on whether they had done enough to keep her safe. To Mia’s mother Chloe, the answer was obvious. “We reached out for help during the most vulnerable time in Mia’s life,” she told the court, “but she didn’t get the help she needed.” In a written statement after the jury delivered its verdict, she promised that she “will never forgive” the Becton Centre. 

For the vast majority of her short life, Chloe told the court, Mia was a happy child. “She laughed her way through life and always had a smile on her face. She would often sing like no one was watching; she was so confident and powerful in everything she did.” She had a particular passion for horse riding and, throughout the hearing, Chloe kept a knitted doll of her daughter in riding gear close at hand.

But, in the month before her death, something shifted. At Christmas in 2023, Chloe recalls, Mia “went from hysterical and crying to extremely happy” and began hitting herself after she became convinced there was a bug in her ear. Chloe and Mia’s step-dad Martin were so worried that they made a decision to seek help in the new year. Before they had a chance, Mia suffered an episode on New Year’s Eve so concerning that they called an ambulance, after she “tried to get a knife out of the drawer and said she wanted to kill herself and go to heaven, as that’s what the voices were telling her to do”. Mia was taken to her local hospital in Nottingham, the Queen’s Medical Centre.

It’s obvious Mia was a difficult patient. On her first night in A&E, Chloe recalls her daughter “running around screaming, banging on doors and shouting that we were going to die if we didn’t leave the hospital”. She had to be kept in a separate room, was restrained and sedated on eight occasions and eventually needed four mental health nurses allocated to her alone. Though the hospital performed an MRI scan and a blood test to rule out a physical cause for Mia’s psychosis, which several witnesses noted is incredibly rare in such a young child, no other tests were carried out. “I got the impression they wanted to get Mia out of the hospital as soon as they could,” Chloe told the court. Her daughter was a patient there for just four days when the hospital ruled out a physical illness, had her detained under the Mental Health Act and began looking for somewhere else to send her.

This week, almost two years since Mia’s death, it emerged the hospital was wrong. Halfway through proceedings, the inquest took a drastic turn when pathologist Professor Marta Cohen told the court she had carried out further tests that proved Mia was suffering from autoimmune encephalitis, a rare condition where the immune system attacks the brain, which can cause extreme psychiatric symptoms. Further tests in hospital, such as an EEG or a lumbar puncture, might have caught the infection. The question of suicide was thus taken off the table — since Mia was, quite literally, not in her right mind — and Chloe wept in the court, finally vindicated in her fervent belief that her bright and bubbly daughter hadn’t truly wanted to die. Following the inquest, Dr Manjeet Shehmar, medical director at Nottingham University Hospitals NHS Trust, apologised to the family. “While this is an incredibly rare condition and initial tests were negative, we recognise that further testing may have had an impact on her future, for which we are truly sorry."

For Sheffield Children’s NHS Foundation Trust, which runs the Becton Centre, this was also highly significant news. Mia would have needed high-dose steroids and possibly donated antibodies or a plasma exchange to cure what ailed her — not the group sessions, art therapy and psychiatric medication their staff were able to provide. Becton Centre was not the right place for her after all. 

However, though the Becton Centre was handed a patient with an ailment they could not treat, the jury noted that problems with communication between staff and risk management meant they did not respond adequately to the danger Mia posed herself. Normally when reporting on cases where someone has ended their own life, journalists avoid being too specific about the method they used, both as a courtesy to their loved ones and because of the risk of inspiring similar attempts. In this instance, it is impossible to fully explore what the Becton Centre could have done differently without including some information about how Mia hurt herself. The rest of this article contains details some readers may find distressing.

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Mia arrived at the Becton Centre on 9 January 2024 and the jury was told about five incidents during her time there, with the fifth being the successful attempt on her life, which took place at some point between 11 and 11.30pm on 29 Saturday. Chloe told the court she rang the Becton Centre every day at 8am and 9.30pm and initially drove from Nottingham to Sheffield seven days a week to visit her daughter, before realising her constant absence was beginning to affect Mia’s little brother. After that, she visited five days a week and sent other family members for the remaining two days. “I spoke to them a lot during her time there but I feel I was not always told the full extent of what was happening,” she told the court. Choking back tears, she added: “I would never have left Mia alone if I knew.”

In the morning of 15 January, just under a week after she was admitted, Mia told staff she’d had a nightmare of a man strangling her. Nurses spotted what looked like a red rash on her neck and eventually Mia admitted she’d caused the mark by holding her bedsheet hard against her neck. “I suggested they remove the bedding and other items from her room to prevent this happening again,” Chloe told the court, “but they told me they were not allowed to do so to retain her dignity.” When asked why items Mia could use to harm herself were not removed from her room, Dr Lavelle said this would be “far more restrictive” than was appropriate. “To remove everything someone could use to tie round their neck would mean removing all clothes and everything,” she said. 

Three days later, in the evening of 18 January, Mia became so agitated that she pulled out a chunk of her hair and later emerged from the bathroom with her dressing gown cord tied around her neck, which staff quickly removed. When Chloe was informed about this incident over the phone, she asked why staff didn’t stop Mia from pulling her hair out and was reportedly told “she was not harming herself enough to warrant restraining”. She was also told her daughter “had been banging her head against a wall” and, when she arrived for her visit that day, saw she “had a swollen forehead and two black eyes”. She told the court she was then told these injuries were actually from Mia “falling into the wall because she was drowsy”.

Eight days later, at around 6am on 26 January, Mia asked for her iPad and became upset when a nurse refused to let her have it. Seemingly in response, she yet again tied something around her neck, although she complied with staff when they asked her to stop.

When asked about the incidents on 18 and 26 January, Dr Lavelle told the court that, at the time, she felt Mia “was someone seeking help rather than trying to end her life,” since on both occasions she made it obvious to staff what she was doing. “Our feeling was that this was her way of saying she was really struggling but didn’t have the words to tell us that she needed more help to settle and to soothe,” Dr Lavelle said. “We considered it a really good sign that the therapeutic relationship was starting to build and that she sought support from staff at the time.” The day after the incident on 26 January, the court heard Mia was downgraded from a high to a medium-risk patient for the first time since arriving at Becton Centre. She remained medium-risk until her death. 

In the early morning on 29 January — less than 24 hours before she ended her life — Mia again tied her bedding around her neck. Staff noticed what she was doing and ordered her to let them into her room, reminding her they were able to open her door from outside if necessary, and she complied. While the court heard from Becton Centre staff that Mia’s behaviour seemed “overt”, she had not shut her bedroom door during any previous incidents. 

That evening, Mia did the same thing again. However, on this occasion, no one noticed — a support worker who was sitting in the nearby nursing office around this time said he didn’t see or hear anything unusual. By the time he checked on her at 11.30pm, as scheduled, she was already unresponsive. 

Chloe recalls she received a missed call from the Becton Centre 45 minutes later. “When I called straight back, a nurse told me everything was ok,” she told the court. “I then received a voicemail while on the call and called back and the nurse told me Mia had ligatured and was receiving CPR as she had a pulse. I later found out this was not true.” By the time she arrived at the A&E in Sheffield, at 1.15am, her daughter had been declared dead. 

For Chloe, one of her most burning questions about Mia’s care at the Becton Centre is why her unstable daughter was left alone long enough to put herself in danger. Following the incident on 26 January, “I told them I was concerned she’d had enough time between observations to tie bedding around her neck,” she told the court. “I was extremely worried at this point that something would happen due to her unpredictable behaviour but felt my concerns were not taken seriously.” 

When Mia first arrived at the Becton Centre, she had a staff member within arm’s reach at all times while in communal areas — primarily to monitor her behaviour around the other children — and was checked on every 15 minutes while in her bedroom. By 22 January, however, staff decided she had settled enough that it was safe to only check on her every 30 minutes, whether she was in a communal area or her bedroom. 

The court also heard that any member of staff, including nurses and support workers, could make a unilateral decision to increase how often Mia was checked if they felt she was in immediate risk. Despite the two concerning incidents that followed her observations being decreased, on the mornings of 26 and 29 January, this change was never made.

When asked why Mia’s observations were not increased, Dr Lavelle told the court that Mia found being closely observed “incredibly difficult and traumatising,” which meant “there was a real risk, if we increased her observations, that it would have made her feel worse.” She added: “Observations are a way of checking if someone is safe but they’re also very invasive and can make someone more risky. It’s not as simple as saying that a higher level of observations keeps them safe.” 

Deputy clinical nurse manager Karen Croad recalls arriving for her shift at 7.30am on 29 January, shortly after the incident with Mia that morning. “As I walked in, one support worker said ‘thank god you are here, there’s only three of us’,” she told the court, explaining that three of the six staff working the day shift were running late. A staff member called Tracy — who was not called to give evidence during the inquest — told her she was documenting what Mia had just done but didn’t seem to feel it was more worrying than previous incidents. Croad says she was told Mia “was really noisy, shouting, waving her arms about, looking round to make sure people were looking” and that it therefore “felt like she wanted people to come to her and talk to her”.

The court heard that, during a day at the Becton Centre, there are four in-person handovers as staff arrive for their shifts, during which they are told how every patient has been during the last 24 hours. Staff who miss this meeting, which lasts approximately half an hour, are told to read a written version. Because the incident involving Mia on the morning of 29 January was taking place while this handover document was being written, it was not included at the time. Croad told the court she believed Tracy had added the incident to this document, as well as updating Mia’s personal records, but later learned this was not the case. 

As a result, though the incident was discussed during the in-person handover at 7.30am, the three staff who arrived late and read the written version never learned it had taken place. One of these staff members was responsible for giving the in-person handovers at 9am and 7.30pm, meaning these two groups of staff were also not told. While Croad gave the handover at 4pm, the court heard conflicting evidence about whether she remembered to mention what had happened with Mia. Croad insists she did, whereas mental health nurse Timothy Collins told the court he could not recall this being discussed. If he had been told, he added: “I would have a note of it and I would have perhaps asked why there was not an increase in observations. Even if there had not been, I would have checked her more frequently anyway, because I have got a duty of care.”

However Croad, one of the staff present during the day who knew about this incident, insists she saw no reason to worry about Mia’s risk to herself during the rest of her shift. Though Collins noted that Mia’s mood dipped after a difficult visit with her family at around 8pm, Jessica Baker — Mia’s “named nurse,” who arrived for a night shift at 7.30pm — remembers finding her in a cheerful mood. “Mia was very happy to see me and was on her iPad talking about her future plans of the mobile hairdressers she was going to set up in the back garden with her auntie,” she told the court. “She had picked the colour scheme and was really excited to show me and other people.” Like many staff at the Becton Centre, she remembers Mia as a bright and friendly child when her mood was stable, with “a real zest for life” and plans for the future.

The court heard that each patient at the Becton Centre has a named nurse who “should be more aware of things that are going on for that young person” than other staff. However, 29 January was the first time Baker had worked a night shift since Mia had arrived. As a result, it did not strike her as unusual that Mia, who the court heard from other witnesses usually asked for her bedroom door to be propped open because she was afraid of the dark, asked her to close it fully after she was put to bed that night. Tearing up, she told the court: “She was yawning and rubbing her eyes, she looked like a tired child. I thought she wanted privacy and, as far as I was aware, she wanted to go to sleep.”

Baker was not aware of the incident involving Mia’s bedding that morning and, again choking back tears, told the court she noticed there was no cover on Mia’s duvet and so put one on. At this time, she also noticed there was a second duvet in the wardrobe. “I remember looking at it and wondering why it was there but thinking it was really late and I could see Mia was really tired. If I started moving her room around and taking things out, it could potentially cause her distress,” she said. “At that point, I didn’t know a duvet cover could be a risk so there were no alarm bells in my head.” When asked if knowledge of the morning’s incident would have meant she reacted differently, Baker said: “I think that’s an impossible question to answer because I don’t know how I would react to information I didn’t have. It’s something I have thought about a million times over.”

Despite not knowing about the incident early on 29 January or what happened on 15 January — due to what she described as a “communication breakdown” — Baker insisted that staff at Becton Centre would have been constantly considering Mia’s risk to herself. “As a mental health nurse, my job is to constantly risk assess, that’s what I do all the time every second of the day.” However, when asked if she spoke to Mia about the incident on 26 January, she said she could not recall whether she did or not. “From what I knew about Mia, she was quite reactive and was able to tell us when things were hard for her,” she told the court. “I knew if she wanted to talk about something she was struggling with, she would either talk to me about it or present herself in a way that was concerning.”

In a statement sent after the conclusion of Mia’s inquest, Dr Jeff Perring, executive medical director at Sheffield Children’s NHS Foundation Trust, said the trust is “deeply sorry for Mia's death”. Since then, he said the trust had “carried out a thorough review of her care and have made significant changes,” including ensuring all staff can access clinical records, which reassured the coroner that she did not need to write a report on how the trust could prevent future deaths. He added that the CQC most recently inspected in September and “found the centre to be safe and staff there caring and responsive to patient needs” but that the trust “will now carefully reflect on the evidence heard and the coroner’s conclusions to ensure we continue to provide safe and compassionate care.”

For Mia’s family, however, the ordeal is not over. “I will never recover from what happened to Mia and I’ll continue to fight for full accountability and justice for Mia being denied the amazing life I know she would have gone on to enjoy,” Chloe wrote. “The hole she leaves behind is vast and impossible to fill; every day without her feels incomplete. She was a shining star when she walked this earth and now she’s a shining star in heaven. She will be forever remembered, forever cherished and forever loved.”