Critical signs were missed by staff for a tragic suicidal teenager
from various sources – October 2017
submitted by – Sobia Begum Hussain
news updates will be listed at the foot of this item
Edward Mallen who was an 18-year-old teenager whose ‘secret’ despair had not been disclosed to his parents by mental health staff. He had been offered a place at Cambridge University and everything appeared well, yet he took his own life at Meldreth rail crossing near Cambridge on 9 February 2015.
Edward left home at lunchtime and went into Hills Road Sixth Form College to hand in some homework. On his return after lunch, he left the train at Meldreth, his home village and took his own life by jumping in front of an express train shortly after 3pm and was killed instantly just a few hundred yards from the home where he grew up.
Police appealed for witnesses to come forward if they hear from anyone who might have seen him minutes before his death or have any information.
An Inquest held in Huntingdon heard how the Edward had seen his GP two weeks before his death and had given consent for his parents to be told about his thoughts and feelings however they were not informed. His Mental health worker Duncan Maxwell told the Inquest that if the conversation was made known to Edward’s parents it would have had been beneficial. The medical director of Cambridgeshire and Peterborough NHS Foundation Trust, Dr Chess Denman, admitted there were things that disclosure should have been handled differently.
The Doctor that treated Edward told the inquest that Edward was depressed and experienced suicidal thoughts. Concerned, he contacted Cambridgeshire and Peterborough NHS Foundation Trust Crisis intervention team recommending Edward was to be seen within 24 hours. But a triage mental health nurse who spoke to Edward on the phone said a five-day wait was more appropriate as he did not think there was a significant risk.
On 26 January he attended his appointment at Fulbourn Hospital and was told by telephone the next day that he would receive a routine referral to an assessment psychiatrist in the post. A letter was sent, dated 29 January, offering an appointment with a psychiatrist on 24 February, but it was never received as it was incorrectly addressed.
Having heard nothing from the Trust and with his condition deteriorating, Edward confided to his mother that he had been self-harming and needed help. In view of the lack of confidence in the Trust, Edward’s parents felt that they needed urgent help for their son and subsequently visited a private psychologist near Cambridge.
After the 2-day inquest the Coroner returned a verdict of suicide. Assistant Coroner, Belinda Cheney, recorded that Edward had died from multiple traumatic injuries as a result of having been struck by a train.
Tragically, Edward could not see a way out of his situation. “During this inquest, concerns have been raised about the funding of the mental health services. Sharon Allison, a medical negligence specialist and also the Mallen’s family lawyer said; “The loss of Edward Mallen is a catastrophic tragedy. What we see in this case, together with countless others, is the continued disjointed, under-resourced and isolated way healthcare agencies work in relation to mental illness, particularly in young people.
“This leads to trauma and tragedy as patients fall through the cracks in a broken system which lacks transparency and accountability. The current system is totally unacceptable. But I’m optimistic that the attention this case has attracted will help to turn the tide in this crisis.”
Edward’s father said his death proves the mental health system in England is “not really fit for purpose” and was “underfunded and overwhelmed”. He even thought that the Mental Health system to a degree contributed to his son’s death.
Steven Mallen also said that he believed Edward had a disease; “Mental illness is a disease that is totally indiscriminate. I don’t think the health service understand this. In my mind, there are structural failures, both in this case and in the system. Illnesses like this are entirely treatable and preventable. Had Edward received the proper help, he should have made a full recovery.”
Steven founded the MindEd Trust charity to raise awareness of the issue of underfunding in the NHS.
The Cambridgeshire and Peterborough NHS Foundation Trust held an internal enquiry and commissioned an independent report into Edward’s death and a spokesman said the trust was “implementing the recommendations” of both.
Dr Marin Baggaley, a consultant psychiatrist at the NHS who investigates serious incidents involving patients or former patients, said the professionals who spoke to Edward did all they could as during the interviews they had with him , he was not presenting any signs that would be any cause for alarm.