Inquest into preventable death following poor mental health care

Amanda Cavanagh, Associate at Ashtons Legal, provides the following statement on behalf of the family.

“Our family are heartbroken and devastated by the loss of Madie and need time to consider the conclusions of the Coroner today.

The inquest has been particularly distressing as we heard how Madie was trusted into the care of Ipswich Hospital to a ward with an amateurish and incompetent approach to mental health, safeguarding and risk.

During the two weeks of witness’ evidence, it was admitted that neither Doctors nor Nurses consistently read notes, reviewed risk assessments, shared important information which we believe would have prevented Madie’s death.

Hearing both NSFT and ESNEFT argue amongst themselves as to who was responsible for Madie’s care and who should have responded to the direct warnings only added further insult to significant injury. Madie was our daughter and their death was entirely foreseeable and preventable.

We are extremely grateful to the Coroner for his very meticulous, thorough, detailed and considered review of the events surrounding our beloved daughter’s unnecessary death. The attention, care and compassion demonstrated by the Coroners Court was in stark contrast to the care Madie received at Ipswich Hospital. The sad fact is it won’t bring Madie back or repair the permanent heartbreak and trauma.

We hope that lessons will be learnt to avoid another child and family having to go through the indescribable pain and torment we have endured. We also hope that changes are made to prevent such tragedies from happening again”.

To watch Amanda read the statement on behalf of the family, please click here: Ipswich parents of Madeleine Savory react after inquest