21st September 2016

Neglect by one of England’s largest mental health trusts contributed to the death of a boy, a coroner has ruled.

Chris Brennan, 15, died at Bethlem Royal Hospital, south London, in August 2014. He had been admitted six weeks before after incidents of self harming.

The coroner found a lack of a risk assessment and an up-to-date care plan had contributed to his death.

The number of self-harming incidents on the unit had “desensitised” staff to the dangers, said coroner Selina Lynch.

Chris, who had mental health problems, repeatedly harmed himself while he was at the adolescent unit, which is run by the South London and Maudsley NHS Trust.

South London Coroner’s Court found there was no discussion about the number or seriousness of the incidents in a care meeting that took place days before he died from asphyxiation.

‘National scandal’

The court heard the unit was struggling to cope with basic functions, due to staffing issues, which led to poor morale and performance.

His family said: “Losing our beloved son and brother when he was just 15 years old was so painful.

“Losing him as a result of the hospital’s failure to protect his life is unbearable. Chris will never be forgotten and no other child should be allowed to die in this way.”