Chris Brennan inquest: Hospital neglect 'contributed to teenager's death'
Neglect by one of England's largest mental health trusts contributed to the death of a boy, a coroner has ruled.
Chris Brennan, 15, died at Bethlem Royal Hospital, south London, in August 2014. He had been admitted six weeks before after incidents of self harming.
The coroner found a lack of a risk assessment and an up-to-date care plan had contributed to his death.
The number of self-harming incidents on the unit had "desensitised" staff to the dangers, said coroner Selina Lynch.
Chris, who had mental health problems, repeatedly harmed himself while he was at the adolescent unit, which is run by the South London and Maudsley NHS Trust.
South London Coroner's Court found there was no discussion about the number or seriousness of the incidents in a care meeting that took place days before he died from asphyxiation.
The court heard the unit was struggling to cope with basic functions, due to staffing issues, which led to poor morale and performance.
His family said: "Losing our beloved son and brother when he was just 15 years old was so painful.
"Losing him as a result of the hospital's failure to protect his life is unbearable. Chris will never be forgotten and no other child should be allowed to die in this way."
In a statement the trust offered its "sincere apologies" to Chris's family.
It added: "Areas of learning for the trust were identified through a serious incident investigation and we have carefully reviewed our procedures accordingly.
"More recently, the service has been inspected by the Care Quality Commission and care was found to be of a 'good' standard. We hope this offers some reassurance to the family that lessons have been learnt from this very tragic event."
Chris is one of 11 young people to have died in psychiatric units in England between 2010 and 2014, according to the charity INQUEST which provides advice to people bereaved by a death in custody.
Outside court, the family's solicitor, Tony Murphy, said: "The family supports the calls for (Health Secretary) Jeremy Hunt to commission an independent review into the deaths of children in psychiatric hospitals."
He added that deaths in psychiatric hospitals were not investigated by an independent body pre-inquest, which meant that coroners had to rely on evidence gathered by the very organisation under investigation.
Deborah Coles, director of the charity Inquest, which represented the family, said: "The lack of resourcing of child and adolescent mental health services across the country is a national scandal."