A coroner has demanded pressing modifications at an NHS belief over failings in its psychological well being care after an inquest dominated a teenage woman killed herself after claiming that she was sexually abused from the age of seven.
Maziellie Mackenzie, often known as Mazie, took her personal life aged 14 following a collection of failings by NHS trusts concerned in her care.
Social providers grew to become concerned in Mazie’s life a month earlier than her first birthday when she and her mom, Wendy, have been discovered to be residing in a automobile in Cumbria.
In June 2018, she went lacking whereas on a visit to a playground in Heysham beneath the care of The Cove, which is run by Lancashire and South Cumbria NHS Basis Belief (LSCFT).
Lower than 4 hours after she disappeared, her physique was present in a secluded woodland space and he or she was pronounced lifeless on the scene.
Final October, Assistant Coroner Phil Holden concluded that Mazie’s loss of life was suicide and revealed his intention to carry an additional listening to, to search out out what modifications had been made on the NHS belief.
The coroner has now despatched as a Prevention of Future Deaths report back to LSCFT, giving them 56 days to formally notify him of steps taken to enhance providers at The Cove, saying that future deaths will in any other case be doubtless.
Maziellie Mackenzie (pictured above), often known as Mazie, took her personal life aged 14 following a collection of failings by NHS trusts concerned in her care
After repeated and common cases of going lacking, Mazie mentioned that she was being sexually exploited by drug sellers in an effort to repay hashish money owed.
Mazie additionally claimed she had been sexually abused by quite a few males from the age of seven, however her mom refused to imagine her and known as her a liar.
In Might 2018, aged 14, Mazie moved to a specialist residential care house for victims of kid sexual exploitation in Yorkshire. She rapidly settled in and have become good mates with a resident.
Workers on the house developed a detailed bond with Mazie. However Mazie was unable to flee her previous and the alleged abuse she had suffered by the hands of these she ought to have been in a position to belief. She instructed employees on the house how she had been sexually exploited when she was youthful.
The allegations have been formally reported to Cumbria Police. However no one was ever arrested in reference to the 11 investigations which have been ongoing on the time of Mazie’s loss of life.
In his letter, which has additionally been despatched to Mazie’s household, Mr Holden mentioned: ‘Throughout the course of the inquest the proof revealed issues giving rise to concern. For my part there’s a threat that future deaths will happen except motion is taken.
‘Within the circumstances it’s my statutory responsibility to report back to you.
‘The issues of concern are as follows; Skilled proof was heard (and accepted) at inquest that there was no written coverage/doc in place by the Belief which set out the circumstances during which group depart from the Cove ( and different tier 4 models) is granted and who’s accountable for the granting of such depart, {that a} necessary threat evaluation is required and setting out an inventory of things/standards that should be thought of earlier than any group depart is granted, setting out the employees to affected person ratios for any group depart and figuring out the factors to be thought of.’
In a press release, LSCFT mentioned: ‘We might as soon as once more prefer to reiterate our deepest sympathies to Mazie’s household and mates. We admire that any inquest is tough for the family members concerned, and significantly so when the loss of life is that of a youngster.
‘Since this tragic occasion in 2018, we’ve used the training from our investigation to make enhancements within the unit, for instance, how we handle escorted depart. The security of our service customers is our high precedence, and we’re dedicated to repeatedly bettering.’
Across the age of 1, Mazie was positioned in momentary look after a month and, upon returning to her childhood house in Barrow-in-Furness, the authorities had no various however to step in on quite a few events amid fears for her security.
When she was simply 5 Mazie instructed a social employee that her mom was utilizing medication.
When Mazie was eight, social providers flagged up considerations about her mum’s consuming and use of medication and three years later.
In September 2014, Wendy was arrested on suspicion of kid neglect. Presently Wendy was seeing a person known as Gary – a relationship marred by a ‘vital sample of alcohol consumption’, arguments, and their ‘lack of awareness about the way it affected Mazie’.
By 2016, when Mazie was 13, social providers acknowledged that the time had come to take their intervention to the subsequent stage and thru the household courtroom obtained an interim youngster safety order; and later a full care order, to retain custody of Mazie, a course of which mum Wendy didn’t oppose.
From then on Mazie grew to become what is called a ‘looked-after youngster’.
After repeated and common cases of going lacking, Mazie (pictured) mentioned that she was being sexually exploited by drug sellers in an effort to repay hashish money owed
Between Might 2016 and July 2017 Mazie was positioned with three completely different foster households in Barrow and Dalton however every placement ultimately broke down due to her advanced emotional wants and behavior.
She spent eight months in a youngsters’s house in Barrow, between July 2017 and March 2018, throughout which period it grew to become obvious that Mazie was in pressing want of extra intensive assist.
By the center of 2018 Mazie’s self-harming had escalated. Workers on the house in Yorkshire not felt they might preserve her protected.
On Might 14, Mazie was left distraught after talking to her mom on the telephone and listening to the voice of one in every of her former companions within the background.
‘She could not imagine her mum had received again with him’, the inquest heard.
The next day, because of her misery at discovering her mom was again together with her ex, Mazie was taken to York Hospital in Might 2018 however docs did not observe coverage and didn’t undertake a full psychological well being evaluation or refer Mazie to the Little one and Adolescent Psychological Well being Providers.
It was then recognised that Mazie wanted to be positioned in what is called a Tier 4 unit – an in-patient setting for younger individuals with advanced psychological well being wants, however the numerous hospital trusts which had been concerned in her care could not agree which ones ought to fill within the type to refer her to such a spot.
Mazie was initially from Cumbria however when admitted to York Hospital had come beneath the care of York and Scarborough Instructing Hospitals NHS Basis Belief and, latterly, that of Mid Yorkshire Hospitals NHS Belief when she was admitted to Pinderfields Hospital in Wakefield.
This disagreement led to Mazie being left in limbo, in a youngsters’s ward at a hospital in Wakefield, for 3 weeks.
Ultimately the scientific director of Cumbria’s Little one and Adolescent Psychological Well being Providers, Barry Chase, determined sufficient was sufficient and, disregarding protocol, put his identify to a referral which might enable Mazie to maneuver to The Cove in Heysham.
Three weeks after shifting to Heysham, Mazie went on a visit to a close-by playground, on June 23 in 2018, together with three different ladies and two members of employees.
When the women refused to return to The Cove and ran away from the 2 healthcare assistants Mazie additionally went lacking.
Throughout the area of round 20 minutes the opposite ladies have been discovered, and agreed to return to The Cove, however Mazie was nowhere to be seen.
The final sighting of her was at round 7pm when a nurse from The Cove noticed Mazie on the bypass whereas on her approach into work.
Errors in how Mazie’s disappearance was logged by Lancashire Police meant that it was nearly two hours earlier than officers started looking for her.
At simply after 10pm, lower than 4 hours after Mazie had disappeared, a gaggle of youngsters got here throughout her physique in a secluded woodland space.
Regardless of the efforts of law enforcement officials who have been first on the scene and tried to resuscitate her, Mazie was pronounced lifeless at 11.03pm.
On the conclusion of the inquest, the belief mentioned in a press release: ‘We want to reiterate our deepest sympathies to Mazie’s household and mates.
‘We admire that any inquest is tough for the family members concerned, and significantly so when the loss of life is that of a youngster.
‘Since this tragic occasion in 2018, we’ve used the training from our investigation to make enhancements within the unit, for instance, how we handle escorted depart. The security of our service customers is our high precedence, and we’re dedicated to repeatedly bettering.’
MailOnline has reached out to the belief for additional remark.
Anybody searching for assist can name Samaritans free on 116 123 or go to Samaritans.org