An agency care worker who failed to supervise a suicidal teenage girl at a scandal-hit mental health hospital was working under a fake ID and fled the country shortly after she died, an inquest has heard.
Ruth Szymankiewicz, 14, died after she was left alone at Huntercombe Hospital, near Maidenhead in Berkshire, despite requiring constant one-to-one observation, jurors at the inquest were told.
The hearing was told that the support worker who had been 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.
He left his shift at 8pm when it ended, but should have waited to hand over to another worker before doing so, to ensure Ruth could be watched at all times. But the coroner told the jury he “just left”, meaning Ruth was left alone for 15 minutes.
In that time, Ruth, who had an eating disorder, made her way to her room where she committed an act of self-harm. She was found and resuscitated, and transferred to the local acute hospital, John Radcliffe in Oxford, where she was admitted to intensive care. Ruth died two days later, on 14 February, having suffered brain injury.
Assistant coroner for Buckinghamshire Ian Wade said it later emerged that the worker, who joined the hospital on the day Ruth was left unattended, had been using false identity documents and was hired through an agency under a false name, Ebo Achempong.
“The evidence showed he had been employed through an agency, who checked his identity documents, and they even trained him by putting him through a day or day and a half course,” Mr Wade told jurors.
“It appears that these particular processes were the norm and were sufficient to enable a hospital to employ this person. But on 12 February, he did not keep Ruth under a constant watch.
“Some time around eight in the evening, this man ended his shift without knowing where she was and without making sure that he handed her over to another member of staff to continue the one-to-one care regime.
“He simply left.”
Mr Wade continued: “It turned out he wasn’t Ebo Achempong, that was a false name. He had been assisted to acquire a false identity documents, and he never returned to work at Huntercombe.”
After Ruth’s death, police tracked down the worker’s phone, which revealed he had gone “to Heathrow airport and got on a plane to Ghana”.
The coroner said police think they know “who he truly was”, but that he was “never seen again” after leaving the country.
“It seems that he learnt what happened that evening,” Mr Wade said. “He let Ruth down. He let everyone down.”
The inquest, which started on Monday, heard Ruth should have been under continuous one-to-one observations and watched at all times following a suicide attempt on 7 February.
When Ruth was left unsupervised, she was able to asphyxiate herself, the coroner said. A post-mortem examination carried out by the Home Office later determined the preliminary cause of death to be “hypoxic ischemic encephalopathy” – a type of brain damage due to lack of oxygen.
After Ruth’s death, the Care Quality Commission launched a criminal investigation alongside the police. Police have taken no further action. The CQC has not stated whether it will take forward a prosecution.
The court further heard that the privately run Huntercombe Hospital had been inspected twice by the CQC prior to the incident.
“The CQC had not reported favourably on Huntercombe,” the coroner told the inquest.
The Huntercombe Hospital in Maidenhead, also called Taplow Manor, closed in 2023 after joint investigations by The Independent and Sky News. It was part of a group, formerly run by The Huntercombe Group and now taken over by Active Care Group.
Ruth’s parents, Kate and Mark, who are both doctors, read out a pen portrait for their daughter describing her as “cheeky, kind, blunt yet deeply thoughtful”.
“Ruth was born in 2007, our firstborn and the first baby within most of our friendship groups and social circles. She was born with a head of bright red hair, perhaps the first indication of the fiery, determined and at times stubborn side of her. But that red head was also a sign of her huge heart, of her deep passion for life and the huge well of love she had within her.”
They said Ruth was “intelligent, creative with a spirit that made her unforgettable”, and that “she lived life wholeheartedly” and “had big ideas she wanted to help the world”.
“She died at the age of just 14, too young … Her death has shattered us, her wider family, and it’s had a profound impact on all of us.”
Ruth had suffered from Tourette syndrome and a tic condition, which had impacted her mental health. She was also diagnosed with an eating disorder, all conditions which emerged during and after the Covid-19 pandemic.
In the weeks before her admission to Taplow Manor, she was admitted to a general acute ward at Salisbury Hospital, where she spent a few weeks following a self-harm attempt. At the time, she was under the care of the local community child and adolescent mental health team. While at Salisbury, she suffered a “traumatic” incident in which her nasogastric (NG) tube, used for feeding, was inserted into her lungs.
On 4 October, with no other beds available, Ruth was sent to Taplow Manor, tens of miles away from her home and family.
Ruth’s mother, Kate, told the court that the family were pressured and told that there was no choice when they were told by doctors that their daughter would be admitted to Thames Ward, at Taplow Manor, which is a psychiatric intensive care unit.
These units are wards for the most severely mentally unwell children, and guidance says patients should be on these wards for just 8 weeks. However, Ruth was on the ward from October 2021 until her death in February 2022.
In a statement to the court, Ms Szymankiewicz described a series of concerns over the care of her daughter, including that the family were only able to see their daughter twice a week.
She said the family were not told of several self-harm attempts and injuries. Ruth, according to her mother, had no access to psychological support and had just two sessions with an assistant psychiatrist in the four months before her death, she told the court.
“Her days were shaped by being restrained, NG fed and watched by staff. She said, ‘Do I need to hurt myself so I can go to a normal hospital?’
“She was desperate, nothing displayed that more poignantly than the note Ruth left before she died…
“We felt we had to push for information. You could see Ruth was deteriorating. Ruth was being provided with so little therapeutic care,” Ms Szymankiewicz said.
She also described how their daughter was given unsupervised access to her phone on the ward despite her parents raising repeated concerns.
In December, on a visit home for Christmas, Ruth grew anxious at the thought of going back to hospital. She allegedly told her parents she would “rather die than go back to Thames Ward”.
She was so distressed that she had to be taken back to hospital in handcuffs and foot restraints, an incident her mother described as “traumatic.”
Five days before the fatal self-harm attempt, Ruth was able to self-harm in a very similar fashion after she was left alone for 30 minutes, the court heard. Ruth’s parents found out she was supposed to be on 15-minute observations, down from constant; however, after the 7 February incident, observations were increased to constant again.
Ending her statement, Ms Szymankiewicz said of her daughter: “She was managed and contained and not helped. The things Ruth had to endure would’ve felt like torture to her and something she would’ve done anything to escape.”
“The loss of a child, I don’t think anyone who hasn’t experienced it can truly understand … We hope the process of unpicking her story might influence the care of others going forward.”
The inquest at Buckinghamshire Coroner’s Court in Beaconsfield continues.
If you are experiencing feelings of distress or are struggling to cope, you can speak to the Samaritans in confidence on 116 123 (UK and ROI), email [email protected], or visit the Samaritans website to find details of your nearest branch. If you are based in the USA, and you or someone you know needs mental health assistance right now, call or text 988, or visit 988lifeline.org to access online chat from the 988 Suicide and Crisis Lifeline. This is a free, confidential crisis hotline that is available to everyone 24 hours a day, seven days a week. If you are in another country, you can go to befrienders.org to find a helpline near you.
For anyone struggling with the issues raised in this article, eating disorder charity Beat’s helpline is available 365 days a year on 0808 801 0677. NCFED offers information, resources and counselling for those suffering from eating disorders, as well as their support networks. Visit eating-disorders.org.uk or call 0845 838 2040
