Mia Lucas, described by her mother, Chloe Hayes, as “a beautiful soul who loved life and loved her family”, experienced a dramatic change in behaviour in the final weeks of her life. She began hearing voices and became aggressive, prompting growing concern from her family.
Three weeks after the onset of her “acute psychotic episode”, Mia was detained under the Mental Health Act. She was later found unresponsive in her room at the Becton Centre, part of Sheffield Children’s Hospital, on 29 January last year.
An inquest has since found that doctors at Queen’s Medical Centre (QMC) in Nottingham failed to test for autoimmune encephalitis, a rare but treatable swelling of the brain known to trigger acute psychosis. A lumbar puncture, which was not performed, would likely have detected the condition.
The diagnosis only emerged midway through the nine-day inquest, when a pathologist reported newly received post-mortem findings.
In its narrative conclusion, the jury stated: “The failure to undertake a lumbar puncture at this point (at QMC) meant that potential indicators of autoimmune encephalitis were missed. This possibly contributed to Mia’s death.”
Hayes said: “My beautiful little girl has lost her life and I will never forgive the Queen’s Medical Centre or the Becton Centre for failing her. Listening to how she was let down when she needed specialist care for the first time in her life has been devastating.
“She was dismissed at the Queen’s Medical Centre, who wrongly concluded there was no physical cause for her psychosis. Appropriate tests were not carried out, and she was passed on to mental health services as quickly as possible, which led to her transfer to the Becton Centre.”
The jury also found that staff at the Becton Centre failed to adequately address the risk that Mia might harm herself.
Hayes said she did not believe her daughter ever intended to take her own life. “For 12 years she was a happy, healthy child who adored her family and had so much to look forward to,” she added.
The inquest heard that Mia’s symptoms began over Christmas 2023, including hearing voices and, at one point, attacking her mother. On New Year’s Eve, the family became so alarmed that Mia was taken to QMC by ambulance.
Senior Sheffield coroner Tanyka Rawden said she would be writing to Health Secretary Wes Streeting and various medical bodies to raise concerns about the absence of national guidelines for testing suspected autoimmune encephalitis.
Rawden directed the jury to confirm that Mia died from “compression of the neck”, caused by “acute psychosis”, itself caused by “autoimmune encephalitis”.
Dr Manjeet Shehmar, medical director of Nottingham University Hospitals NHS Trust, said: “We accept the coroner’s findings and apologise to Mia’s family for not identifying autoimmune encephalitis while she was in our care. Although the condition is extremely rare and initial tests were negative, we acknowledge that further investigation may have altered her future, and we are truly sorry.”
Dr Jeff Perring, executive medical director at Sheffield Children’s NHS Foundation Trust, offered condolences, saying: “Our thoughts are with Mia’s family and everyone grieving her loss in such tragic circumstances.”
The trust said it had reviewed Mia’s care and implemented “significant changes” since her death.
