Teen took own life after care delays, inquest told

A teenager apparently took her own life after NHS mental health teams did not immediately involve a psychiatrist in her care, an inquest has heard.

Ischia Montagu La Placa, 16, was found dead at her home in Lyme Regis, Dorset, on 16 February 2024.

She met NHS crisis workers but did not see a psychiatrist despite a series of self-harm incidents in the weeks before her death, the inquest in Bournemouth was told.

Barrister Paul Clark, representing her mother, suggested Ischia's care was "not escalated quickly enough".

The teenager, who grew up in Henley-on-Thames, Oxfordshire, was "generally well" until the beginning of 2024, the inquest heard.

On 4 February, she was taken to hospital after ingesting a substance.

She was assessed by the NHS trust as being at medium risk and was referred to its Enhanced Support and Liaison (ESL) team, a crisis service.

On 11 February, there were further self-harm incidents, the inquest was told.

The teenager's mother, Fiamma Montagu, rang for help from a family friend, Dr Alison McCowat, who was a consultant psychiatrist with Dorset HealthCare University NHS Foundation Trust.

Dr McCowat told the hearing: "I didn't have the sense that there was an immediate, immediate risk."

She added that a hospital stay or a meeting with a psychiatrist was sometimes counter-productive in such cases and was not routine for patients.

On 12 February, the ESL service escalated concerns about Ischia to West Dorset's Core Child and Adolescent Mental Health Service (CAMHS), another part of the same NHS trust.

However, Chris Wilcox from CAMHS said access to a psychiatrist was not immediately discussed.

He told the hearing Ischia's situation "felt risky, but there were attempts to contain it by the ESL team".

On 14 February, Ischia disappeared, leaving a suicide note, before being found by police and returned home.

The police report, which might have triggered an escalation in care, was not sent to NHS carers, the inquest heard.

The NHS trust told the hearing it had improved clinical oversight and updated procedures as a result of the teenager's death.

Dorset Senior Coroner Rachael Griffin said she would consider whether to raise concerns about possible delays in care for future patients when she issues her conclusions on Wednesday.

In a statement before the inquest, Fiamma Montagu paid tribute to her "beautiful, fun, charismatic" daughter.

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