A 14-year-old girl was unlawfully killed when she died at a children’s mental health ward after an agency worker with a fake ID left her alone, an inquest jury has ruled.
Ruth Szymankiewicz, who was being treated for an eating disorder at Huntercombe Hospital in Berkshire, was under strict one-to-one observation when the staff member responsible for her walked away on February 12, 2022.
The worker, then known as Ebo Acheampong, had never worked in a psychiatric hospital before and was on his first shift at Huntercombe, an inquest at Buckinghamshire Coroner’s Court heard.
A police investigation later found he was hired by the Platinum agency – which supplied staff for Huntercombe Hospital – under a false name. He never returned to work at the hospital following the incident and fled the UK for Ghana.
The ward was missing at least half of its staff on the day Ruth, who had self harmed several times in the past, was left unsupervised.
Mr Acheampong was originally working on a different ward, but was asked to join the team because they were so short-staffed nurses could not go on breaks.
Ruth, who had to be kept within eyesight at all times, was able to lock herself in her bedroom on the psychiatric intensive care unit where she self-harmed. She died two days later at the John Radcliffe Hospital in Oxford.
Jurors wept as they recorded their conclusion, as well as the coroner and members of Ruth’s family.
Ruth Szymankiewicz (pictured), 14, died after she was left alone long enough to asphyxiate herself despite being under a ‘level three observation’ which required constant watch
Ruth (pictured), who was being treated for an eating disorder at Huntercombe Hospital in Berkshire, was under strict one-to-one observation when the staff member responsible for her walked away on February 12, 2022
The worker, then known as Ebo Acheampong, had never worked in a psychiatric hospital before and was on his first shift at Huntercombe, an inquest at Buckinghamshire Coroner’s Court heard. Pictured: Ruth
A police investigation later found the worker was hired by the Platinum agency – which supplied staff for Huntercombe Hospital – under a false name. He never returned to work at the hospital following the incident and fled the UK for Ghana. Pictured: Ruth
A risk management form known as a ‘Datix incident’ had been filed on the day by Michelle Hancey, a support worker with 18 years’ experience at Huntercombe, who raised concerns that the Thames ward team would ‘fail to monitor patients on prescribed special observation because of staff shortage’.
During the inquest, jurors were shown CCTV of the moment Mr Acheampong left Ruth unsupervised as she sat in the ward’s lounge watching TV, allowing her to walk out.
She had been placed on the ‘level three observation’ plan following earlier incidents of self-harm – meaning she had to be kept within eyesight at all times.
Footage showed Mr Acheampong leaving the room repeatedly – at first for seconds, then for two minutes – before Ruth walked to the door and looked into the lobby, appearing to wait for a chance to leave.
She was last seen on camera walking out of the day room alone and going straight to her bedroom, shutting the door behind her, coroner Ian Wade KC said.
About 15 minutes later, a nurse found her and raised the alarm.
Ruth (pictured) was last seen on camera walking out of the day room alone and going straight to her bedroom, shutting the door behind her, coroner Ian Wade KC said. About 15 minutes later, a nurse found her and raised the alarm
Ruth’s parents, Kate and Mark, a GP and a surgeon, told the inquest their daughter’s care was ‘terrible’. Today an inquest jury returned a conclusion of unlawful killing
During the inquest, jurors were shown CCTV of the moment Mr Acheampong left Ruth (pictured) unsupervised as she sat in the ward’s lounge watching TV, allowing her to walk out
Huntercombe Hospital (pictured) had been inspected twice by the Care Quality Commission (CQC) prior to the incident, the inquest previously heard. It was rated as ‘overall inadequate’ in a CQC report dated February 2021.
The jury foreman told the hearing: ‘Ruth’s (pictured) care pathway … was insufficient to allow improvement for discharge. From Ruth’s admission to Thames ward, her responsible clinician deemed the ward to be neither suitable nor conducive to her recovery’
Today an inquest jury returned a conclusion of unlawful killing.
‘Ruth was not prevented from accessing the restricted material which could be used to self-harm,’ the jury foreman told the hearing.
‘Ruth was not prevented from accessing harmful material on the internet.
‘Ruth’s care pathway … was insufficient to allow improvement for discharge.
‘From Ruth’s admission to Thames ward, her responsible clinician deemed the ward to be neither suitable nor conducive to her recovery.
‘Ruth’s parents were not given adequate information about the appeal process, and refusal rights.’
In an emotional statement after the inquest, Ruth’s parent’s Kate and Mark, both doctors, said: ‘There is an empty space at our table, a silent bedroom in our home, a gaping hole in our family that will never be filled.’
‘When, at our most vulnerable as a family, we reached out for help, we ultimately found ourselves trapped in a system that was meant to care for her, to help her, to keep her safe, but instead locked her away and harmed her.’
They said while at Huntercombe, Ruth was denied access to the love and support of her family, and left ‘isolated, scared and alone’.
‘She was essentially caged’ and ‘withdrew more into herself as she tried to navigate and survive months in a poorly trained, understaffed and unsafe ward.
‘She was trapped. With no one to comfort her, no one to try to alleviate her suffering, no one to cuddle’.
They said that while the conduct of the worker who left Ruth alone was shocking, there were ‘numerous systemic failures’ and it was ‘paramount that the other wider and more important issues are acknowledged and addressed’.
A tearful assistant coroner for Buckinghamshire Coroner’s Court, Ian Wade KC, thanked the jury and told Ruth’s family: ‘I hope you will treasure all the good memories of your lovely daughter.’
Huntercombe Hospital had been inspected twice by the Care Quality Commission (CQC) prior to the incident, the inquest previously heard.
It was rated as ‘overall inadequate’ in a CQC report dated February 2021.
Active Care Group, which owned Huntercombe at the time of Ms Szymankiewicz’s death, has since closed the facility.
