‘We've learnt lessons since Ella's death'

Hospital bosses say changes are being made after failings were found in their care of a 13-year-old who took her own life. Ella Louise Murray died on November 15, 2023, at King’s College Hospital in London after struggling with her mental health. A four-day inquest was held in December at Oakwood House in Maidstone where area coroner Catherine Wood said the teenager was “crying out for help”.

The hearing was told that two days before she died, Ella was taken to A&E after telling her teachers at Highsted Grammar School in Sittingbourne “she wanted to kill herself”. For confidential support on an emotional issue, call Samaritans on 116 123 at any time or visit www.samaritans.



org. The Year 9 student was first seen by a paediatric nurse at Medway Maritime Hospital, who referred her to the Child and Adolescent Mental Health Services (CAMHS). She was then seen by a mental health nurse who deemed she was a “medium risk” and discharged Ella from the department with an agreed home treatment plan.

The court heard the next day, Ella, of Alexandra Road, Sheerness , was seen by another mental health nurse from North East London NHS Foundation Trust (NELFT) which provides CAMHS in Kent. According to the assessment notes, the “fearless” and “competitive” rugby player for Aylesford RFC told the practitioner she would “hurt herself or others” if she stayed at home. The court also heard the teenager had asked to be admitted to the hospital, but she did not meet the criteria.

After the nurse left, Ella attempted to end her life and was airlifted to King’s College Hospital, where she died the following day (November 15). During the inquest, the court heard referrals were made to Front Door, a service used to report safeguarding concerns, and to Kent School Health, a team of school nurses and practitioners, for counselling sessions. The hearing was also told the family was receiving support from Kent County Council (KCC) Early Help, which provides initial support for families, were paying for counselling and Ella’s GP had referred her to CAMHS.

If you want to talk to someone confidentially, click here . In her findings, Mrs Wood said she found it “incredible” that a 13-year-old could tell a nurse she was going to harm herself and a risk assessment was not completed. She added: “I simply cannot accept it is reasonable to leave her at home even with a plan to see her the following day.

There was a clear failure here to keep Ella safe. “This was a child crying out for help, and I find she should have been risk-assessed. Had she been, she would have been high risk.

” Mrs Wood declared that Ella should have been taken to a mental health bed and admitted to the hospital, or an urgent discussion should have been held with partner organisations to ensure Ella was in a safe place. She concluded that Ella died by suicide shortly after being seen by mental health professionals who she had told that she wanted to end her life. Ms Wood added: “There was a failure to undertake an adequate, or any, risk assessment and take any further steps to ensure Ella's safety.

" The coroner has since written a Prevention of Future Deaths (PFD) report to the Secretary of State for Health and Social Care, the chief executive of NHS England and the Kent and Medway Integrated Care Board (ICB) outlining her concerns. She stated there was no shared access to Ella’s records for those involved in her care, she did not meet the criteria for a hospital bed, there was no way to arrange an urgent multi-agency meeting and “no urgent steps were taken” to ensure her safety. The report added: “Had steps been taken to share information between her school, social services and the mental health providers when she attended the emergency department on November 13 or early the following day, rather than leave her at home, she may have been removed from her home and may still be alive today.

“No one agency involved had access to all the relevant information and concerns about Ella across the health, social care and education arenas. “Evidence given suggested that shared records would assist, but the ability to respond to urgent concerns would require a system change. “If a multi-agency meeting had been convened, this may have prevented Ella’s death, and such action may reduce the risk of death for other children being in a similar position.

” In response, the chief nursing officer at NHS Kent and Medway ICB assured the coroner that multiple meetings and reviews had taken place since Ella’s death, with multiple agencies present. In particular, the letter highlighted the work NELFT is doing to address Mrs Wood’s concerns, including creating a child-focused safety plan which would be shared with the person’s school and social worker. It has also agreed to develop an escalation flow chart for professionals, to include a single point of access contact and a multi-disciplinary team meeting escalation process.

The letter said this work is underway, and the plan is to share it with other partners and then complete an audit once it is agreed on and rolled out. Kent and Medway ICB also confirmed it has implemented the Kent and Medway Care Record (KMCR), which supports inter-agency access to health and social care records. Although there is no plan to have direct contact with education, it explained the Front Door teams will be able to ensure requests are sent to the right service.

NHS England’s national medical director also acknowledged the failings highlighted in the PFD and said it echoed recommendations made from previous reviews into the suicides of young people. It stated that a 2020 safeguarding partnership review in Kent and a 2021 suicide report from the National Child Mortality Database recommended improved information sharing between agencies. The latter showed that across 108 deaths, the most common issue was poor communication and information sharing between professionals.

However, the letter said the recent Children’s Wellbeing and School Bill is looking to address this by strengthening the role of education in safeguarding arrangements and creating a clearer basis for information sharing. It added: “NHS England is keen to assure the coroner and Ella’s family that the concerns raised about Ella’s care have been listened to and reflected upon. “Ella’s case includes learnings for teams across NHS England and local organisations, as well as more broadly.

” Speaking previously to KentOnline following the inquest, Ella’s mum Natalie James said her daughter was “crying out for help” and had been “let down” by those she entrusted to help her. She continued: “She would have helped anybody, but when she needed help, she did not get it. She was just a job to them, a statistic, but she was our whole world.

“I do not want any more Ellas or parents sat here but from what I have heard there will be more. “Parents should always trust their instincts. If they think professionals are not making the right choices, they should speak up.

” Ella’s family and friends have set up a TikTok page, LifeWithoutElla, to help support others who may be struggling and to raise awareness around young people’s mental health..