Steps Taken to Address Failings
Delivering her conclusion, Ms Wilkes acknowledged that since Evelyn’s death, steps have been taken to address some of these failings. Improvements include new s.117 aftercare procedures for children and young people within Lincolnshire, improved methods of communication between parents and clinicians at the Beacon hospital and a new mental health policy at Kesteven and Grantham Girls School.
Ms Wilkes also praised Evelyn’s mother, Jenni, for her collaborative work with health bodies to drive changes in the system and improve the support available to young people struggling with mental health challenges.
Speaking following the inquest, the family’s lawyer Charlotte Andrews, a public law solicitor from Simpson Millar, welcomed the fact that lessons had been learnt, saying that the findings will ‘bring some relief’ for the family who ‘tirelessly advocated for their daughter during her care and continue to do so today’.
Tributes to Evelyn and Reflections on the Inquest
Paying tribute to their daughter, Evelyn’s mother and stepfather, Jenni and Jack Swift, said: “The inquest touching on the death of our daughter Evelyn has concluded this week. Evelyn was incredibly loved and is profoundly missed by so many people. She made us proud every single day and continues to do so. Evelyn left this world far too soon, creating an indelible void, but we will be eternally grateful to have had the joy of her in our lives.
Commenting on the hearing they added: “We are grateful for the Coroner’s thorough and detailed investigation, and her compassion for us as a family. We are also grateful for the witnesses who have been forthcoming with their evidence and their reflections. As anyone can imagine, reliving our daughter’s death, and the traumatic years leading to her death has been very difficult, and we have been grateful for the sensitivity and dignity we have been treated with. Whilst we have been taken back to some devastating events, we have also been reminded of the input of some remarkable and dedicated professionals involved in Evelyn’s care.
Coroner’s Conclusions and Evelyn’s Words
“The Coroner concluded that Evelyn died by suicide. She found that a lack of clear and appropriate discharge planning made a contribution to Evelyn’s death. This vindicates the struggle we had over the lengthy time of Evelyn’s inpatient treatment, where our concerns were repeatedly dismissed. It shouldn't have taken Evelyn's death for our voices to be heard.
“There were also a number of things that didn’t directly cause Evelyn’s death, but which concerned the Coroner, including missed opportunities early on in Evelyn’s care, and with respect to poor use of language for young people who struggle with their mental health and/or have an eating disorder.
Systemic Failures and Progress
“The Coroner found that in respect of the NHS Trusts involved in Evelyn’s care, that the operational duty under Article 2 was engaged. Evelyn was discharged from inpatient care at the Beacon hospital in March 2022 because the ward environment was no longer safe for her. However, Evelyn remained exceptionally vulnerable, and there was and remained an exceptional risk to her life.
“The Coroner found that Evelyn did not receive the aftercare that she was assessed as needing, and to which she was entitled under s.117 of the Mental Health Act 1983. Lincolnshire Partnership NHS Foundation Trust (LPFT) admitted that parts of the policy regarding the aftercare that Evelyn should have had after she was discharged from hospital were not in place. We heard that a lot of work has been done on the aftercare procedures since and there are further improvements in progress, for example to address the lack of mental health crisis support for children and young people and their families in Lincolnshire.
Honouring Evelyn’s Memory Through Advocacy and Kindness
“The Coroner powerfully read out Evelyn’s own words during her summary, taken from an English assignment Evelyn wrote in 2021: “I can’t help but wonder if I was first diagnosed and given the help when I first reached out would things be different now. Would I still have spent so long in hospital. Would I have got to the point where people were worried for my life. Would things still have been the same”. Although sadly too late for our daughter, we hope the new changes to mental health services prove beneficial for other young people and their families.
“The Coroner’s investigation included the first ever application to OFCOM under the Online Safety Act 2024, which only came into force on 1 April 2024, for disclosure of material from social media services relating to the investigation into the death of a child. This did not lead to the discovery of any specific trigger for Evelyn, which in itself was of interest and gave reassurance to the Coroner and of course our family.
“We were privileged to have Evelyn in our life for nearly 16 years and continue to spread her kindness through #evelynsbutterlyeffect, which was set up in her memory and encourages everyone to spread kindness through their actions towards others.
“As a family we are grateful to many wonderful charities and organisations who supported us throughout Evelyn’s illness and indeed since her death, including Parenting Mental Health, Beat (Eating Disorders), Young Minds, C.A.L.M, Survivors of Bereavement by Suicide (SOBS) and Amparo. Evelyn said she didn’t want others to go through what she went through, and moving forward we will continue to advocate for young people struggling with their mental health, for the improvement of services, and continue being a voice for our beautiful Evelyn.
Acknowledgement and Guidance on Reporting
Charlotte Andrews, a public law solicitor from Simpson Millar, who supported the family at the inquest, said: “Evelyn’s family tirelessly advocated for their daughter during her care and continue to do so today. The Coroner’s investigation has allowed their voice, and Evelyn’s, to be heard, and the findings today bring some relief as they continue to come to terms with their loss.
“The Coroner was clear that the fact that she did not make a report under Regulation 28 to prevent future deaths, was down to the development of the policies after Evelyn’s death, where representatives of the Trust acknowledged the remarkable contribution by Jenni.
“Jenni and Jack’s involvement with Kesteven and Grantham Girls School has also transformed their policies. Lessons have been learned.”
Jenni and Jack Swift were represented by Charlotte Andrews of Simpson Millar Solicitors, instructing Harriet Short of One Pump Court Chambers.
Evelyn’s family would also like to draw attention to the Samaritans guidelines on reporting suicide.
