Penelope Schofield warned that there was a “clear risk” that young people would succumb to mental illness if urgent action were not taken, as she said she had written to Sajid Javid, the health minister. The medical examiner concluded that Robin Skilton, 14, committed suicide after being disappointed by “major failures” in the NHS. The failures were so severe in the case of the suicidal teenager – who was repeatedly rejected for evaluation – that Ms. Schofield found the NHS guilty of “neglect”. Robyn, from Horsham in West Sussex, disappeared from her 70 670,000 family home and was hanged in a park on May 7 last year, with a long history of self-harm and suicidal ideation. At that time, England was in the second step of the government’s roadmap outside of lockdown and interference between different households was not allowed. Despite “real serious concerns” about her mental health, Robin did not receive face-to-face consultations, visit a child psychiatrist or be evaluated for mental health issues and was discharged from the NHS a month before her suicide. The “red list” of the high risk. He was referred to a city council support program, but was kept on a waiting list for a one-on-one consultation for ten months. Eventually, when he had a consultation, it was just a remote session due to the pandemic. Robyn’s father, Alan Skilton, a software company manager, kept asking the authorities for help.
“Amazing” lack of care
He told his daughter’s research that the lack of care she received was “amazing”. Ms Schofield, who has chaired a number of high-profile investigations, including the Shoreham Airshow disaster, said she would report to the government after the hearing. “As a society, we fail young people,” Schofield warned. Ms Schofield said she was “shocked” when she heard evidence during the two-day hearing that the number of young people seeking mental health care had risen by 95 per cent in recent times. He said: “Trying to manage it without more resources means that we do not provide the help that young people need. “Robin’s case is proof of that. “There is a clear danger that more lives will be lost if we do not deal with it. “Therefore, I will write a report on the Prevention of Future Deaths to the Minister of Health to address these concerns.” Ms Schofield added that young people “need resources to get the help they need”. Ms Schofield ruled that there were “major setbacks” for the Sussex Partnership NHS Foundation Trust in the case of Robyn and the Sussex Mental Health Service for Children and Adolescents [CAMHS].
“I have to come to a conclusion of neglect”
He said: “I appreciate the landscape in which the Trust worked as Covid-19 increased the level of complexity, but there were many failures in the care it provided to Robyn. “All of these failures, in my mind, mean I have to come to a conclusion of neglect. It was a serious failure to provide care to someone in a dependent state. “Robin committed suicide while fighting with her mental health. “Robyn mental health services failed because they did not recognize her deteriorating mental health, nor did they provide her with the care she needed. “Negligence also contributed to her death.” Dr Alison Wallis, clinical trustee of the Trust for Child Services, told Robyn’s parents, crying, “you did not get the service you deserved” and that Covid influenced their care. Mrs Schofield described the main weaknesses.
“We did everything we could to help”
These included CAMHS ‘failure to assess it “appropriately or not at all”, which led to missed opportunities to meet its “escalating needs” for several years, but “especially in April 2021, when it was clear that there was a risk to life”. . Ms Schofield said there had been a failure to arrange face-to-face consultations, a lack of direct communication, a failure to offer her CAMHS treatment when she met her criteria and a failure to “evaluate Robyn at any time”. It ruled that “the decision to discharge her from CAMHS and instead treat her for autism was inappropriate” and that Robyn should have seen a child psychiatrist. Robin’s father, who attended the Chicago investigation with his wife and Robin’s mother, Victoria, said “we did everything we could to help” the teenager. He said: “We believe that if Robin had seen correctly earlier … her mental health would have improved and she would not have committed suicide.” Robyn was “extroverted, sociable and easily made friends”, enjoyed ballet, gymnastics and swimming and was “naturally artistic” and enjoyed singing and dancing. However, her problems started at the end of 2018, after she moved to Mallais School in Horsham exclusively for girls last year.
Listening to voices
Robin suffered from mental health disorders, repeatedly injured herself, attempted suicide and was hospitalized four times, later telling doctors she heard voices and saw images. She was referred to the West Sussex County Council Emotional Youth Support Service and attended group sessions but was not supported and was kept on a waiting list for a one-month consultation for 10 months. Eventually, when she had a consultation, it was not effective as it was remote due to the pandemic. CAMHS initially did not take her on, even though it met her criteria, and when the service did, it focused on trying to assess her for autism. Her parents said self-harm was a “coping mechanism”, Robin did not receive check-ups twice a week and did not speak directly to her on CAMHS. Mr. Skilton was “shocked” Robyn received a self-questionnaire to complete when she committed suicide and was repeatedly disappointed that she was not kept in the dark by the authorities due to “confidentiality”.
“Our appeals for help have been rejected”
“The hospital just seemed to be doing an exercise trying to get her discharged,” Mr Skilton said. “Even when he threatened to jump off a bridge, our calls for help were rejected.” Robyn said “no one could help her” and that “she was looking forward to ending her life”. In early 2021 he was rushed to hospital because he tried to overdose on paracetamol and stayed for three nights. Mr Skilton said: “We were surprised that after he attempted suicide he left the hospital with less support. “No one seemed to take her mental health seriously.” Mr. and Mrs. Skilton became “desperate” at Robyn’s lack of help near her death, asked CAMHS if they could dismember her, and considered admitting her to Priory for 1.3 1,300 a night. Mr Skilton said in the days before her death “her mood changed completely” and this gave her parents “false hopes”.
Lost chances
Lawyer Rebecca Agnew, of the Sussex Partnership NHS Foundation Trust, admitted that “CAMHS misjudged Robyn, leading to missed opportunities for her escalating needs.” She added: “The Trust is formally apologizing to its parents for these failures. “The Trust did not adequately assess Robyn and did not provide her with the care and assistance she needed, and this contributed more or less, negligently or negligently to Robyn’s death.” Giving evidence, CAMHS senior practitioner Carly Mendy admitted: “It was inappropriate to fire her.” CAMHS clinical specialist Velani Bhebhe admitted that the risk assessment for Robyn was not “detailed enough”. The Sussex NHS Trust has begun making major changes to its mental health services, and Ms. Schofield will reconvene the investigation in three months to evaluate them.
