12-year-Old Dies After Missed Diagnosis of Rare Brain Disorder, Inquest Finds
Nottingham, UK – A 12-year-old girl tragically died after medical staff at two healthcare facilities failed to identify a rare autoimmune brain disorder, an inquest concluded today. Mia Hayes, who was experiencing acute psychosis including hearing voices and attacking her mother, took her own life after a series of failings in her care, according to a jury’s findings.
The inquest heard that Mia was taken by ambulance to queen’s Medical Center (QMC) in Nottingham on New Year’s Eve after a rapid deterioration in her mental health.She was subsequently sectioned under the Mental Health Act after being diagnosed with an “acute psychotic episode.” Initial blood tests and an MRI scan at QMC showed no obvious physical cause for her condition.
However, the jury found that clinicians at QMC did not request further tests, including a lumbar puncture to check for signs of autoimmune encephalitis – a condition where the body’s immune system attacks the brain. “The failure to undertake a lumbar puncture at this point [at QMC] meant that potential indicators of autoimmune encephalitis were missed. This possibly contributed to Mia’s death,” the jury stated in their narrative conclusion.
The inquest also highlighted concerns about communication between QMC and the Becton Centre, where Mia was transferred on January 9th. The jury determined that details shared between the facilities ”provided an inappropriate level of assurance that organic causes had been ruled out.”
Further, the Becton Centre was criticized for “insufficiently robust communication and management of risk,” leading to a failure to adequately respond to Mia’s risk of self-harm. Mia died three weeks after her transfer to the Becton Centre.
The senior coroner for South Yorkshire (West), Tanyka rawden, directed the jury to find that Mia’s cause of death was compression of the neck, caused by acute psychosis, which in turn was caused by autoimmune encephalitis.
Following the inquest, Mia’s mother, Chloe Hayes, delivered a powerful statement. ”It has been devastating to listen to how, when she needed specialist healthcare for the first time in her life, she was so badly let down,” she said. ”She was let down at the Queen’s medical centre in Nottingham,who wrongly decided there was no underlying physical cause of her psychosis,and failed to carry out appropriate testing. I believe they simply dismissed her and looked to pass her on to mental health services as quickly as possible, which led to her transfer to the Becton centre.”
Mrs. Hayes continued, “Her mental health spiralled deeper out of control there, as she was not being treated for her condition, and the many failings and lack of care meant sadly she wasn’t properly protected from harming herself.” She concluded, “My beautiful little girl has lost her life and I will never forgive the Queen’s medical centre or the Becton centre for failing her.”
Dr. Manjeet Shehmar, the medical director at Nottingham University Hospitals NHS Trust, issued an apology. “We accept the coroner’s outcome in court today and apologise to Mia’s family for not identifying autoimmune encephalitis while she was in our care,” Dr. Shehmar stated. “while this is an incredibly rare condition and initial tests were negative, we recognize that further testing may have had an impact on her future, for which we are truly sorry.”
