The death of a teenager who fatally self-harmed at a scandal-hit mental health hospital after being left unsupervised by a worker using a fake ID was unlawful, an inquest jury has ruled.
Ruth Szymankiewicz, 14, died on 14 February 2022 following a litany of failings at Huntercombe Hospital, also called Taplow Manor, near Maidenhead, where she required constant one-to-one observation, Buckinghamshire Coroner’s Court heard.
In the 15 minutes she was unsupervised, Ruth, who had an eating disorder, Tourette syndrome and a tic condition, which had affected her mental health, made her way to her room, where she self-harmed. She was found and resuscitated before being transferred to John Radcliffe Hospital, where she died two days later.
Huntercombe Hospital was closed in 2023 after investigations by The Independent revealed accusations of systemic abuse against patients, with claims from families that children were “treated like animals”.
During Ruth’s inquest, it was revealed that the careworker responsible for monitoring her was working under a fake ID and had completed just a day or a day and a half of online training before his first shift. Police were not able to question him following her death as he had fled the country.
Uncovering a string of failings in her care, the inquest heard that the ward Ruth was on was “severely short-staffed” and missing “at least half” of its workers on the day she self-harmed, the inquest heard.
In a note written by the teenager before her death, which was read aloud in court, Ruth, who had to be force-fed daily through a tube and often had to be restrained by staff, criticised the lack of therapy available for patients at the hospital, which she said had an “unsafe number of staff”.
She wrote: “I don’t want this to happen to any other patients ever. My suggestion is to shut this place down.”
In a damning conclusion, the jury found that “Ruth was not prevented from accessing the harmful [online] material” that she used to fatally self-harm, and that her care plan was “insufficient to allow for improvement [in her health] and for discharge”.
They also found that the training provided to agency staff by the hospital “was not in line with internal HR policy”.
Jurors found that Ruth’s parents, Kate and Mark, were not given adequate information about her care, while her responsible clinician deemed that the ward she was on was not suitable or conducive to her recovery.
The jury also found that visits to Ruth by her family were limited by the hospital despite their being “integral” to her mental wellbeing.
In an emotional statement after the inquest, Ruth’s parents said: “There is an empty space at our table, a silent bedroom in our home, a gaping hole in our family that will never be filled.
“When, at our most vulnerable as a family, we reached out for help, we ultimately found ourselves trapped in a system that was meant to care for her, to help her, to keep her safe, but instead locked her away and harmed her.”
They said that while at Huntercombe, Ruth was denied access to the love and support of her family, and was left “isolated, scared and alone”.
“She was essentially caged,” they said, adding that she “withdrew more into herself as she tried to navigate and survive months in a poorly trained, understaffed and unsafe ward. She was trapped. With no one to comfort her, no one to try to alleviate her suffering, no one to cuddle.”
They said that while the conduct of the worker who left Ruth alone was shocking, there were “numerous systemic failures” and it was “paramount that the other wider and more important issues are acknowledged and addressed”.
A tearful assistant coroner at Buckinghamshire Coroner’s Court, Ian Wade KC, thanked the jury and told Ruth’s family: “I hope you will treasure all the good memories of your lovely daughter.”
Unlawful killing rulings at inquests are rare; in 2024, there were just 89 such findings from 39,586 inquests.
Mr Wade told the jury on Wednesday that an “unlawful killing” would amount to “gross negligence manslaughter” on the part of the careworker responsible for Ruth’s care.
To come to that conclusion, he said, the jury would have to agree that the worker had breached his duty of care to Ruth; that it was a significant cause of her death; and that the breach was “so reprehensible it amounts to a crime”.
During the inquest, Dr Gillian Combe, a senior NHS doctor working for the Thames Valley provider collaborative, which was responsible for Ruth’s admission, admitted that the NHS did not do enough for the 14-year-old.
Dr Combe said the NHS was aware that the hospital was understaffed daily, and that there were concerns over the care it provided, but there were no other suitable choices available.
Dr Combe has also warned that children’s mental health units across the country are struggling to staff their wards, while the NHS does not have the money to build its own wards.
In 2023, a joint investigation by The Independent and Sky News into a group of hospitals that had been run by the Huntercombe Group before being taken over by Active Care Group, revealed allegations from children at the hospital and their families that they were “treated like animals” and left traumatised as part of a decade of “systemic abuse”.
Patients claimed to have been subjected to the “painful” use of restraints and held down for hours by male nurses. Some said they had been stopped from going outside for months, that they were forced to live on wards with bloodstained walls, and that they were force-fed and given so much medication that they became “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.
In response to the ruling, Active Care Group said: “We extend our heartfelt condolences to Ruth’s family, friends, and all those affected by her passing. We deeply regret the tragic event that occurred, and we are truly sorry for the distress this has caused and recognise the profound impact it has had on everyone who knew her.”
The group said it was disappointed that a third-party company it had hired had breached its terms of contract, though it did not state what the breach of contract was. It also said it had made improvements to the quality and safety of its services since.
Wes Streeting and the Department of Health and Social Care were approached for comment.
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 jo@samaritans.org, 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 www.befrienders.org to find a helpline near you
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