Death of popular teenager leads to coroner's call for mental health service changes

A coroner has called for changes to the borough’s mental health services following the death of an “intelligent” and “popular” teenage girl.

By Rachel Howarth
Tuesday, 23rd July 2019, 5:33 pm
Alicia Sidebotham
Alicia Sidebotham

Alicia Sidebotham was just 19 when she was found dead in woodland near Broadway in Atherton back in January.

An inquest, led by coroner Alan Walsh, heard how Alicia had struggled with her mental health since the age of 14.

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A statement given by her mum, Andrea Sidebotham, described how the “happy” young girl became down and argumentative in her mid-teens.

In a hearing at Bolton Coroners’ Court, Mr Walsh was told how Alicia’s mental health deteriorated, leading to a number of “superficial” self harm incidents and several serious suicide attempts in the years leading up to her death.

Before she reached the age of 16, Alicia had been referred to the Child and Adolescent Mental Health Services (CAMHS), a service which Andrea and Alicia’s dad Thomas Quinn said was “inexperienced” at dealing with their daughter’s issues.

Following a “serious suicide attempt”, Alicia was hospitalised as an inpatient in Chester after her mum demanded that she see a psychiatrist.

“They promised it several times,” she told the coroner.

“I said you need to get a psychiatrist down here or I’m not taking her home.

“He spent 20 minutes talking to her and then she was admitted for nine months.

“There were no adolescent beds in Wigan so she was sent to Chester that night.”

Following treatment at Chester, to which Andrea said she responded very well, Alicia was transferred to Fairhaven Young People’s Unit in Warrington before being moved to Atherleigh Park in Leigh when she was 18.

“She was doing fantastic,” added her mum. “She did well at all the in patient services”.

After making significant progress there, Alicia was discharged into temporary housing at Brookfield in Marsh Green before taking up a more permanent place in Atherton, where she was living when she died.

During this time; Alicia improved vastly, telling her mum she wanted to “catch up on the life she had missed” while she was hospitalised.

She started working at WH Smith as a sales assistant and was described by friends and family as a “normal, sociable” girl.

The coroner heard how, in the weeks leading up to her death, Alicia had stayed with her mum for Christmas and New Year.

Despite being in an occasional argumentative mood, Andrea explained that she was doing well and that she hadn’t indicated she wanted to harm herself in any way.

A post-mortem examination found that Alicia had died by hanging and a toxicology report found cocaine and alcohol in her system, a combination which the pathologist said could have had a “negative” effect on her state of mind.

In the hours before her body was found, she had spoken with her friend who had not suspected anything was wrong.

However a “rational” note left by Alicia in her flat explained why she had chosen to take her life, a note that Mr Walsh said made her intentions “very clear”.

The concerns surrounding her care only became evident after her death, during which time an investigation at North West Boroughs Healthcare NHS Trust (NWBH) found that she was discharged despite the fact that certain meetings had not been held.

Due to Alicia’s previous hospitalisation, the trust was supposed to hold a meeting with her prior to his discharge and inform adult social care at Wigan Council who would continue supporting her within the community for the rest of her life.

An investigation found that this meeting had not been held, but that the decision to discharge her had taken place in November, two months before her death, at a multi-disciplinary team meeting.

Karen Keighley, head of quality at NWBH, explained how Alicia had failed to turn up to an appointment where she would have been discharged, but that this meeting was not rearranged.

The trust attempted to contact her via two phone calls and two letters but a subsequent meeting in October was also cancelled, for reasons unknown.

During the November meeting, the decision was made to discharge her and her care was to be continued by the assigned social worker for Wigan.

Ms Keighley admitted that she did not know if Alicia had ever received a call from the social worker.

On hearing this Mr Walsh explained that he wanted to see changes within the system so that in future a social worker would have to be present at the multi disciplinary discharge meeting so that they were aware that a patient’s mental health treatment had stopped.

He also requested that the mental health service visit any patients ahead of discharge if they have failed to receive a response via letter or telephone.

Despite these concerns, Andrea praised the mental health teams saying that her daughter was not failed by the services but that she wanted the changes to be put in place for those who could have a chance to be helped in future.

“I just think it’s tragic,” she said. “I really really don’t think she was failed.

“There are things I’m concerned about but overall I think she was really really well looked after.

“They couldn’t have done anything differently for her but for other people some aspects should be done differently.

“I would like to thank everybody who looked after her, all her friends and family and mental health services - everybody”.

Mr Walsh gave a conclusion of suicide, saying that he didn’t believe “anything” could have prevented the teenager from taking her own life.

He also said that although Alicia was intoxicated with drugs and alcohol at the time of her death, he did not believe that this had an impact on her decision.

He has advised NWBH to make the changes to their process to help other patients in the future and the trust has agreed.