Staff inexperience linked to teen's death - report

The inexperience of staff at a mental health unit contributed to the death of a 16-year-old autistic girl, a report has stated.

Elise Sebastian, from Southminster near Maldon, Essex, was found unresponsive in her bedroom at the St Aubyn Centre in Colchester, in April 2021.

Coroner Sonia Hayes wrote in a Prevention of Future Deaths Report that staff were not trained in autism and the majority were agency staff with limited experience of working with detained children.

Alex Green, the deputy chief executive of Essex Partnership University NHS Foundation Trust (EPUT), said: "I want to say sorry to Elise's family and to everyone who loved her that she did not receive the care she deserved."

An inquest jury at Essex Coroner's Court in May found that Elise's death could have been prevented if not for multiple failings in her care.

In the report, Hayes added that the centre, which was run by EPUT, did not have sufficient staffing to conduct observations required by the doctors for patients on the ward.

During the time of Elise's admission on Longview Ward, the staff member allocated to carry out observations for patients was required to conduct about 66 observations within an hour, which the report stated "was not logistically possible".

Hayes said management knew that staffing allocation on the ward was not sufficient to conduct the required levels of observations to keep the patients safe, the Local Democracy Reporting Service said.

The ward had introduced an infrared monitoring system called Oxevision to reduce the risk of patients self-harming in isolated areas.

The report said there were difficulties with its roll-out at the centre due to poor wi-fi and the system not operating correctly.

Elise was required to be on constant eyesight observations whilst in her bedroom.

Oxevision imaging showed Elise entering her bedroom alone at approximately 18:10 and she remained in her room until she was found unresponsive at approximately 18:29 BST.

The report stated that staff had also falsified Elise's observation records and this was not identified by the trust during its post-death investigation.

Green added: "I offer my deepest condolences. We will review the coroner's report in full and will respond."

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