Tees, Esk and Wear Valleys NHS Foundation Trust

3. Miss U would like to complain about the following aspects of care and treatment her daughter experienced between 10 and 12 January 2024 by the Trust, specifically: •inadequate risk management and decisions •failed and unsafe transition •missed learning from previous mistakes •poor communication with family surrounding decisions around care.

4. Miss U describes how she has lost her daughter and that it was preventable.

5. Miss U would like the people involved in Miss R’s care to be held personally accountable, and systemic service improvements to prevent this happening to anybody else.

6. Miss R was admitted to a mental health ward at the Trust in March 2021 after self-harming while at university. She remained in hospital for almost three years under section 3 of the Mental Health Act. During this time, she stayed on different types of wards, including psychiatric intensive care, rehabilitation, and acute mental health wards.

7. Miss R was autistic and also had a diagnosis of emotionally unstable personality disorder. Her care focused mainly on her autism. Staff felt she was not ready for formal therapy, and she spent most of her time alone in her bedroom. She used leave from the ward with her family but rarely accepted leave with staff.

8. There was no clear plan to help Miss R leave hospital or improve her quality of life. A meeting in December 2023 decided she should be moved to an acute ward. She was transferred on 11 January 2024.

9. During this transition Miss R was on hourly checks.

10. The next day, Miss R tied a ligature consisting of six socks around her neck in her bedroom and was found unresponsive. Staff raised the alarm and began CPR. Paramedics arrived and took over care. She was taken to hospital but did not regain consciousness.

11. Miss R died on 15 January 2024 at the age of 21. Her family believe she had no brain function from 12 January.

13. Miss U told us she attended a preliminary hearing at the Coroner’s Court on 3 July 2025. The coroner intends to hold a full inquest to look at the cause of Miss R’s death. At this stage Miss U has not been given a date for the inquest. We also note at this time the CQC is carrying out their own investigation and considering whether to take this forward for prosecution.

14. A coroner is an independent judicial officer who investigates deaths reported to them. When a coroner investigates a death, this may include holding an inquest.

15. A coroner’s role does not extend to apportioning blame for a death or considering criminal liability. However, they will comment on the cause of death, and whether any care leading up to it was in any way contributory.

16. An inquest is a limited medical and legal enquiry into the circumstances leading up to the death of the deceased. Following an investigation, a coroner also has the power to report deficiencies in service to the relevant authorities in the hope that improvements will be made to prevent future death.

17. We think it would be appropriate for us to wait until the coroner has completed their deliberations. This is because Miss U believes the care her daughter received at the Trust contributed to her death.

18. With this in mind, we will take no further action on Miss U’s complaint until the Coroner’s Office has completed its deliberations, determined Miss R’s cause of death and, if necessary, reported any deficiencies in service it identifies.

19. Following the Coroner’s Office’s decision, Miss U may feel its findings and reported deficiencies are enough to provide closure for her and her family. If she remains dissatisfied or there are elements of the inquest that do not cover some of the issues Miss U has brought to us, she can return to us.

20. The law says we can only look at complaints if they are brought to us within 12 months of the events complained about. Sometimes, depending on the circumstance we can decide to still consider a complaint outside of this time limit if we have good reasons to do so. Therefore, if Miss U brings her complaint back to us, she should do this as soon as possible and we will consider the reasons for the complaint being outside of our time limit.

21. We understand the events Miss U complains about have had a devasting impact for her and her family. We hope the coroner’s inquest provides Miss U with the answers she is looking for. We also hope Miss U is reassured as to her next steps should she wish to come back to us.

1. We have carefully considered Miss U’s complaint about Tees, Esk and Wear Valleys NHS Foundation Trust (the Trust) and the care it provided to her daughter, Miss R. We acknowledge this period of time was extremely distressing for her.

2. We have decided to take no further action at this time on Miss U’s complaint because the Coroner’s Office has planned to carry out an inquest into Miss R’s death. We explain the reasons for our decision below.