A HOSPITAL trust has made ‘comprehensive’ changes after it failed to undertake a mental health assessment of a teenager from Barrow who had made ligatures, an inquest heard.

The hearing was told that Child and Adolescent Mental Health Services (CAMHS) was not notified, an on-call psychiatrist not contacted, a risk assessment not documented and the proper forms not filled out when Maziellie Mackenzie, known as Mazie, was admitted to York Hospital.

Despite her admission in the middle of the night on May 15-16, 2018, she was discharged but was quickly readmitted to hospital - Pinderfields in Wakefield - with ‘low mood, self-harm and suicidal ideation’. Dr Fraser Scott, who gave evidence at Accrington Town Hall yesterday, saw her here on May 17.

Mazie was tragically found hanged in woodland near Heysham Barrows, Lancashire, on June 23, 2018.

Nicola Cowley, as named nurse in safeguarding at what was then known as the York Teaching Hospital NHS Foundation Trust, conducted an investigation into Mazie’s admittance to York Hospital.

Mazie was twice admitted to the hospital - the first time being in April 2018 - but Ms Cowley’s evidence focused on the second admission in May, when she accepts normal processes were not followed.

She said they would have expected to have seen evidence of procedures such as a risk assessment having been carried out because Mazie was a ‘looked-after child, in care’ and had ‘presented with self-harm’.

She outlined multiple changes that had been made at the trust since that time.

Ms Cowley said that, among these changes, the trust now had a ‘mental health liaison team standard operating procedure’ which outlines ‘step-by-step’ guidance regarding what to do in cases such as Mazie’s.

She said ‘electronic prompts’ had been added to the trust’s systems to ensure that anyone presenting at hospital with evidence of ligaturing could not be discharged until a mental health assessment had taken place.

Dr Scott said that, when he saw Mazie at Pinderfields on the 17th, she was ‘withdrawn, with little eye contact’ and ‘only a few words spoken’.

She was seen by a CAMHS practitioner on May 21, the inquest heard. It was determined at Pinderfields that Mazie’s high level of risk meant she required a ‘tier 4’ bed.

She was discharged at the end of May to The Cove, a specialist inpatient unit for teenagers located at Heysham.

Concern was expressed about a potential delay of many weeks before a person moving to a home in a new area - as Mazie did on more than one occasion - would be seen by CAMHS.

The inquest also heard that CAMHS, at least at the time in question, was only able to visit a person in the community, and not in care, as Mazie was.

The inquest continues.

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