A 12-year-old girl died after being failed on multiple levels by the system meant to protect her, a coroner's court has found.
A Preventable Tragedy
Mia Lucas passed away in January 2024 after being found unresponsive at the Becton Centre, an NHS children's psychiatric unit in Sheffield. The inquest at Sheffield Coroner's Court, which concluded on Thursday 27 November 2025, heard that Mia's death was the result of multiple systemic failures.
Mia had been sectioned and placed at the Becton Centre, which is part of Sheffield Children's NHS Foundation Trust, after suffering an acute psychotic episode. This episode occurred during an assessment at the Queen's Medical Centre (QMC) in Nottingham.
Undiagnosed Condition and Missed Opportunities
The jury found that a critical failure occurred at QMC when medical staff did not perform a lumbar puncture before transferring Mia to the psychiatric unit. This procedure, which involves inserting a needle into the lower back to check for brain or spine conditions, could have revealed the true cause of her symptoms.
Professor Marta Cohen, who testified at the inquest, stated that Mia's official cause of death was compression of the neck. Crucially, she clarified that this act was caused by acute psychosis, which was itself a result of a rare but treatable condition called autoimmune encephalitis.
This condition, an inflammation of the brain that can cause severe psychiatric symptoms, was only confirmed after Mia's death. Consultant paediatric neurologist Mike Taylor described it as complex and rare, noting that while suspicion was low at QMC, experts must always weigh the severe side effects of treatment.
Failures in Supervision and Communication
The inquest jury also identified a second major failure: the Becton Centre did not adequately respond to Mia's known risk of self-harm.
Mia's mother, Chloe Hayes, shared her profound distress with Sky News, stating she was unhappy with the level of supervision her daughter received. All they had to do was watch her, she said. Ms. Hayes revealed she was not fully informed about Mia's previous self-harm attempts until after her daughter's death, adding, If I'd have known the truth I wouldn't have left Mia there.
She believes her daughter, who had so much to live for, was not in control of her actions due to her undiagnosed medical condition.
Anyone feeling emotionally distressed or suicidal can call Samaritans for help on 116 123 or email jo@samaritans.org in the UK. Alternatively, you can call Mind's support line on 0300 102 1234, or NHS on 111.
