Independent report

Serious incident investigation report excerpt: Secretary of State case review into Beth

An excerpt from a report looking at the care and management of Bethany, a Looked After Child (LAC).



The document published here is an excerpt from the complete Serious Incident Investigation Report into the care of Bethany. Bethany was a Looked After Child (LAC) who was reported to have been regularly detained in seclusion for close to 2 years while an inpatient at a child and adolescent mental health service provided by St Andrews Healthcare, a specialist mental healthcare provider. This was disclosed in a programme by File on 4 which was aired on 2 October 2018. Such a prolonged use of seclusion is considered a significant failure of care and warrants full investigation.

This review was requested by the Secretary of State for Health and Social Care under the Serious Incident Framework into the care of Bethany and undertaken by NHS England on his behalf. It has looked the circumstances that led to the care of Bethany at St Andrews Healthcare and the role played by relevant statutory organisations across the system and over time. The review was intended to identify learning that could help prevent such events happening again. It is not intended to apportion blame but to provide an understanding of what happened and how this could be prevented.

At this time, we are disclosing those elements of the final report which we are confident strike the right balance between protecting Bethany’s privacy and promoting transparency in our mental health system. The report itself contains significant personal information about Bethany. We are publishing as much of the report as possible while complying with our duty of confidentiality and data protection requirements.

Published 5 November 2019