The mother of a teenager who died in an Essex mental health unit has made a powerful appeal to the head of a public inquiry, urging her not to let "blood be on your hands" and to implement lasting change. Victoria Sebastian was giving evidence to the Lampard Inquiry in London, which is examining the deaths of more than 2,000 people who were under the care of Essex mental health services between 2000 and 2023.
Her daughter, Elise Sebastian, who was 16 and autistic, was discovered unresponsive in her room at the St Aubyn Centre in Colchester in April 2021. During a four-hour testimony, Ms Sebastian told the hearing that her daughter, who loved animals and Harry Potter, was not properly understood by staff, stating: "They let my daughter die. My daughter meant nothing [to them]. Absolutely nothing."
Ms Sebastian expressed her belief that Baroness Lampard, the inquiry chair, possesses the authority to ensure that the inquiry's recommendations lead to significant improvements. Baroness Lampard has previously affirmed that bereaved families would be central to the inquiry's work, with a focus on identifying systemic failures from which the country could learn. Essex Partnership University NHS Foundation Trust (EPUT), which manages mental health services in Essex, has apologised, stating that Elise "did not receive the care she deserved."
The inquiry heard that a coroner concluded neglect contributed to Elise's death. Ms Sebastian highlighted that Elise began struggling with anxiety at age 10 and also experienced various physical health problems, including a curvature of the spine and bowel issues, which she felt were not adequately investigated. She recounted how Elise was made to feel her concerns were "all in her head" and that she needed therapy, even being considered for Ehlers-Danlos syndrome on the day she died. Ms Sebastian also described the St Aubyn Centre as "not fit for purpose," stating she felt unsafe leaving Elise there, especially after her daughter was reportedly bullied and assaulted by other patients.
Concerns were also raised regarding the staffing and monitoring practices at the unit. Despite Elise requiring one-to-one observations, the inquiry heard she was alone for 28 minutes before her death. With 11 patients on the ward, staffing levels meant a member of staff would have had to observe a patient approximately every 54 seconds. Additionally, staff reportedly relied on infrared Oxevision cameras for monitoring, but poor Wi-Fi connections limited access to information, and emergency alarms were muted. Ms Sebastian called for comprehensive and regularly refreshed training in physical healthcare and resuscitation for mental health staff, a ban on infrared camera monitoring on mental health wards, and increased family involvement in care decisions.