A 16-year-old girl died by suicide after mental health services under the Dorset Healthcare NHS Foundation Trust delayed bringing a psychiatrist into her treatment.
The inquest into the death of Ischia Montagu La Placa, who was raised in Henley, was told that the trust failed to promptly include a psychiatric specialist in her care.
Proceedings before senior coroner Rachael Griffin commenced on September 7 at Dorset Coroner’s Court and examined the mental health support Ischia received prior to her death.
Her mother, Fiamma Montagu, described Ischia as a beautiful, fun, charismatic teenager who was cherished by family and friends alike.
On February 4, Ischia was admitted to hospital following ingestion of a substance.
Further incidents of self-harm occurred on February 11, leading her mother to reach out to Dr Alison McCowat, a consultant psychiatrist employed by the trust and known to the family, for assistance.
The following day, February 12, the Enhanced Support and Liaison service raised Ischia’s case with West Dorset’s Core Child and Adolescent Mental Health Service, which operates under the trust.
On February 14, Ischia left the family home after writing a note and was subsequently located by officers before being returned.
The inquest heard that a police report, which could potentially have prompted an increase in her level of care, was never forwarded to NHS staff managing her treatment.
Representatives from Dorset Healthcare NHS Foundation Trust confirmed to the hearing that improvements had been implemented regarding clinical supervision and that procedures had been revised.
The inquest reached its conclusion last Wednesday.