A teenager who fatally self-harmed at a scandal-hit mental health hospital was unlawfully killed, an inquest jury has ruled.
Ruth Szymankiewicz, 14, died on 14 February 2022 after she was left alone at Huntercombe Hospital, also called Taplow Manor, near Maidenhead in Berkshire, despite requiring constant one-to-one observation, Buckinghamshire Coroner’s Court was told.
Ruth, who had an eating disorder, Tourette syndrome and a tic condition, which had affected her mental health, was left alone for 15 minutes on 12 February, allowing her to make her way to her room, where she self-harmed. She was found and resuscitated before being transferred to John Radcliffe Hospital, but died two days later.
During her inquest, it was revealed that the ward she was on was “severely short-staffed” and missing “at least half” their workers on the day she self-harmed.
In a note written by the teenager before her death, read aloud in court, Ruth criticised the lack of therapy available for patients at the hospital, which she said had an “unsafe number of staff” and “should be shut down”.
In giving the jury’s conclusions for “unlawful killing” the forman said the therapy offered to Ruth was required to be under one to one obesrvations but was left alone between 20:06 and 20:21.
In a damning conclusion the jury round “Ruth was not prevented from accessing the harmful material” which she used to fatally self harm” her care pathway was “insufficient to allow for improvement [in her health] and for discharge.”
That is was “insufficent” in addressing her aversion to nasogastric feeding.
Huntercombe Hospital, Maidenhead, called Taplow Manor, was closed in 2023 following investigations by The Independent revealed accusations of systemic abuse of patients.
It was also revealed in court that the care worker responsible for monitoring Ruth had only gone through a day or a day and a half of online training before his first shift at the children’s psychiatric hospital on 12 February 2022.
The worker who left her had been working under a fake identity, and police were not able to question him following her death as he fled the country.
In a tragic note written by Ruth before her death, read out at the inquest, revealed she had said hospital staff would fall asleep on shift, that there was no access to therapy and that the hospital “should be shut down”.
She said: “Huntercombe , it doesn’t deserve a capital H… It is the shittest mental health institution you could get.. the non-existent therapy, the unsafe number of staff, how the place makes you worse, and the staff literally sleep on their shifts.
“I don’t want this to happen to any other patients ever. My suggestion is to shut this place down.”
During the inquest, a senior NHS doctor working for the Thames Provider Collaborative, which was responsible for Ruth’s admission, admitted that the NHS did not do enough for a 14-year-old who died under the care of a private hospital.
Dr Gillian Combes said the NHS was aware the hospital was understaffed daily, that there were concerns over its care, but there were no other choices available that were clinically appropriate for Ruth.
Dr Combe, has also warned that children’s mental health units across the country are struggling to staff their wards every day and that the NHS does not have the money to build its own wards.
Staff working on the unit on the day of her death revealed it was “severely short-staffed” on the day she self-harmed and was missing around half of the workers it needed that day. A senior nurse and a senior support worker, Michelle Hansey, both revealed that they had raised concerns over short staffing at the hospital to managers before Ruth’s death.
Ms Hancy told jurors that, on the morning of February 12, she had become “upset and emotional” because of the insufficient staffing on the Thames ward.
“I have raised (staffing issues) several times before this event,” Ms Hancey said, adding that a lot of staff had fallen sick during that period because of exhaustion.
It was also alleged at the inquest that on occasions when the wards were short-staffed staffed Huntercombe managers would look for patients whose observations could be reduced.
In 2023, a joint investigation by The Independent and Sky News into a group of hospitals owned by The Huntercombe Group and then taken over by Active Care Group, revealed allegations from children who were at the hospital and their families that they were “treated like animals” and left traumatised as part of a decade of “systemic abuse”.
Allegations included that patients were subjected to the “painful” use of restraints and were held down for hours by male nurses. Some were stopped from going outside for months, were living in wards with blood-stained walls, were force-fed and given so much medication that they had become “zombies”.
In 2017, another young girl died at a hospital owned by the Huntercombe Group. Mia Titheridge, 17, who was supposed to be subject to 15-minute observations, took her own life when a nurse failed to check on her for almost an hour, an inquest found.
Following The Independent’s reports, the Care Quality Commission stopped new admissions to Taplow Manor, and Active Care Group, which took over its running, later decided to close the hospital.
