Failings by a specialist child and adolescent mental health unit 'probably contributed' to the death of a 17-year-old girl in its care, an inquest has found. Lucy Curtis died in hospital on 1 January 2024, five days after being found unresponsive at the Riverside Adolescent Unit at Bristol's Blackberry Hill Hospital. The unit closed weeks later.
A jury at Avon Coroner's Court delivered a narrative conclusion on Friday, stating that delays in obtaining specialist mental health support also 'possibly contributed' to Lucy's death. Her parents, Barry and Michelle Curtis, expressed their conviction that their daughter's death was 'preventable and avoidable', asserting she would still be alive if concerns about her care had been addressed sooner.
Lucy's parents described her as a 'bright, kind and high-achieving' teenager, whose struggles with mental health in early 2023 came as a shock. They detailed how Lucy was referred to Child and Adolescent Mental Health Services (CAMHS) but did not meet the threshold for treatment, instead being directed to a counselling service with a significant waiting list. An independent review of Lucy's broader care noted her GP first referred her to CAMHS in January 2023 due to deteriorating mental health, but this referral was declined. Michelle Curtis stated that this lack of early intervention meant Lucy did not receive CAMHS services until she was actively suicidal.
Lucy was admitted voluntarily to Wessex House, a specialist adolescent mental health unit in Somerset, in August 2023. Her mother highlighted this as a brave decision, reflecting Lucy's desire for help and recovery. However, her parents were not fully aware of the risks associated with in-patient admissions. The independent review reported an escalation in Lucy's self-harm and repeated expressions of suicidal intent while at the unit. Despite being assessed under the Mental Health Act twice, she was discharged in November 2023, a decision her parents remained concerned about. The inquest jury found that Lucy's discharge from Wessex House, which subsequently closed in October 2025, was a turning point and possibly contributed to her death.
Following further incidents at home, Lucy was voluntarily admitted to the Riverside unit on 12 December 2023. Her father had previously raised concerns about an item in her possession that she might use to harm herself. Her parents also questioned the observations carried out on her ward on 27 December 2023, the morning she was found unresponsive, and raised concerns regarding the emergency response. The inquest heard that Lucy was seen at 10:20 GMT but then not again until 10:43, despite being on 15-minute observations. Michelle Curtis believes that had the observation occurred within 15 minutes, the outcome for Lucy could have been very different, reinforcing her view that Lucy's death was preventable and avoidable, both within Riverside and due to the broader lack of early intervention.