‘I will never forgive them’: Jury finds hospitals may have contributed to 12-year-old’s death
A 12-year-old girl who took her own life while detained under the Mental Health Act at a specialist children’s mental health unit in Sheffield was “failed at every stage,” her mother has told an inquest that concluded today.
“My beautiful girl has lost her life and I will never forgive the Queens Medical Centre or the Becton Centre for failing her,” mum, Chloe Lucas, said.
Mia Masie Lucas, from Nottingham, died on January 30, 2024 while being treated at the Becton Centre for Children and Young People in Beighton. She had been sectioned weeks earlier after a sudden and extreme deterioration in her mental health.
Chloe told the inquest that Mia was a “beautiful soul who loved life and loved her family” for the four years before her final illness.
Mia’s mother, Chloe, first took her to the Queen’s Medical Centre in Nottingham after believing her daughter would quickly receive the treatment needed to “get her back to her ‘amazing, friendly, funny’ self as soon as possible,” the inquest heard.
Instead, Mia never returned home.
She died just four weeks after her initial admission, three of which were spent at the Becton Centre in Sheffield.
The inquest heard that this was due to a neuorological condition called autoimmune encephalitis - an "extremely rare and complex" brain inflammation than can cause extreme psychiatric symptoms.
Part-way through the nine-day inquest, it was revealed Mia’s condition may have been triggered by a viral infection she had in December 2023.
Speaking after the inquest, Mrs Lucas said: “It has been devastating to listen to how, when she needed specialist health care, for the first time in her life, she was so badly let down.”
“She was let down in Queen’s Medical Centre in Nottingham. I believe they simply looked past her and passed her on to mental health services as quickly as possible.
“We now know she was suffering from a brain condition which we as a family only found out this week. Yet she was sectioned to the Becton Centre, which was unsuitable for her and failed to keep her safe.”
Mrs Lucas shared the heartbreak she felt after learning about her neurological condition during the inquest: “Mia’s medical cause of death changing nearly two years after her passing is heartbreaking, but also shows the failures and fight we had to endure.”
Jury decision
The jury returned their verdict at the conclusion of the inquest today (November 27, 2025), after more than a day of deliberation.
They found that Mia had become increasingly unwell at the end of 2023, with significant changes in her behaviour that placed her at high risk of self-harm.
Between December 31, 2023 and January 9, 2024, she underwent assessments at Queen’s Medical Centre in Nottingham.
The jury noted that a lumbar puncture was not carried out, meaning potential signs of autoimmune encephalitis were missed - something they said may have contributed to Mia’s death.
Jurors said the information passed to the Becton Centre did not include enough detail about how complete these medical tests were, and provided “an inappropriate level of assurance” that physical causes had been ruled out.
While at the Becton Centre, the jury found that communication and risk management were not robust enough, leading to a failure to adequately respond to her ongoing risk of self-harm.
They added that on the day she was found, better communication and risk procedures could have increased staff awareness and led to more frequent checks.
The jury stated that the evidence demonstrated Mia had a rare presentation of autoimmune encephalitis. They said:
“This rare condition provided particularly complex challenges in reaching an accurate diagnosis and providing appropriate care for Mia.”
Prevention of death report findings
In her report, Senior Coroner Tanyka Rawden set out the changes already made and further actions required to prevent future deaths.
She heard from five witnesses, including staff from Sheffield Children’s Hospital, who confirmed that risk assessments and investigations had been carried out.
Immediate changes at the Becton Centre include replacing doors with secure models that can be safely propped open, fitting sensors that trigger a loud alarm if blocked and carrying out monthly audits.
Staff now have full access to patient records, and handovers have been redesigned. The centre will no longer admit patients without seeing results of tests from other hospitals.
Coroner Rawden said she was “content that changes have been substantial and robust” and that concerns “have been mitigated.”
Rebecca Keeting, an advanced clinical practitioner from Nottinghamshire, said staff are receiving training on recognising physical causes of sudden behavioural changes.
An immediate review means any future case with even “low suspicion” of autoimmune encephalitis will now result in a lumbar puncture.
Investigations at Nottinghamshire University Hospitals NHS Trust are still ongoing, with the cause of Mia’s death (autoimmune encephalitis) only being confirmed three days ago.
Coroner Rawden deferred her decision for six months, directing that she must receive “a detailed statement of any changes” within this time in order to make a decision.
She also highlighted the lack of national guidance on autoimmune encephalitis and plans to issue reports to the Secretary of State for Health, The College of Podiatry and the British Paediatric Association.
In her closing words to Mia’s family, Coroner Rawden said: “I am so sorry she is not with you anymore. She was clearly a little girl with a huge heart and personality and I cannot imagine what you as a family have gone through.”
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