A coroner said failings by an NHS Care Trust contributed to the death of a talented teen who ‘believed she was in the Matrix’.
Christa Goredema, 19, hanged herself at Ridge Lea hospital and was pronounced dead at Lancaster Royal Infirmary on June 27, 2013.
Coroner Dr James Adeley recorded a narrative verdict after a two week jury inquest at Preston Coroner’s Court.
The talented netballer was in the first year of studying BSc (Hons) Sports and Exercise Science at the University of Cumbria’s Lancaster campus but was detained under the Mental Health Act at the time of her death. The coroner said she was suffering from a psychosis at the time and the jury heard earlier in the inquest that the teen – who lived with her mother Jane Mukototsi in Wolverhampton – believed that she was in a fake world ‘like the Matrix’ film.
Dr Adeley criticised Lancashire Care NHS Trust who ran Ridge Lea for underestimating the risk Christa posed to herself. His narrative verdict said: “Christa did not intend to take her own life but her mental state was such that she thought she had to die to return to the real world.
“The risk of Christa’s suicide was consistently higher and increasing but significantly escalated over the last 10 days before her death.
“Christa’s risk of suicide was underestimated by the psychiatric staff due to an overall failure to follow National Health Service Foundation Trust’s policies and procedures.
“During her treatment she did not receive a sufficient dosage of anti-psychotic medication to improve her illness.
“Christa was presenting as high risk and despite evidence that records were lacking in some detailed information, failure to put her on ‘line of sight observation’ contributed to the cause of her death.”
Leon Le Roux, clinical director for adult mental health services at Lancashire Care NHS Foundation Trust said: “The Trust is taking the outcome of the recent inquest extremely seriously and our thoughts are with the friends and family of Christa at this difficult time.
“It is acknowledged that the treatment given to Christa did not fully meet her clinical needs and this is very regrettable;. The Trust has further developed the services it offers to young people experiencing psychosis to ensure they get the right intervention.”
as soon as possible.
“A full and thorough investigation was undertaken immediately after the incident and in addition to this internal review, the Trust has taken on board the comments of an independent expert and an action plan has been completed to make improvements to the service.
“As part of a planned reconfiguration the Trust has also moved out of Ridge Lea into new facilities, The Orchard. This offers a safer environment and the opportunity for patients to find ligature points is reduced by the design features of the unit which are specifically for specialist mental health services.
“A new clinical risk assessment tool is also in place to support clinicians to manage the changing needs of patients and ensure that they are as safe as possible when in our care.”