The mother of a 12-year-old Midlands schoolgirl who took her own life while under hospital care has said she will never forgive the medics who failed to diagnose her underlying brain condition.
Missed diagnosis of rare brain disorder
An inquest jury concluded that inadequate testing at Nottingham's Queen's Medical Centre (QMC) "possibly contributed" to the death of Mia Lucas. The hearing revealed Mia was suffering from undiagnosed autoimmune encephalitis, a swelling of the brain that caused the acute psychosis she exhibited in the weeks before her death.
The rare condition was only identified part-way through the nine-day inquest, when a pathologist presented new post-mortem test results. The revelation caused shock and tears among Mia's family in the public gallery.
A sequence of systemic failures
Mia began behaving strangely over Christmas 2023, hearing voices and becoming aggressive. Her concerned family called an ambulance, and she was taken to QMC on New Year's Eve. She was sectioned under the Mental Health Act after being found to be in an acute psychotic episode.
Although initial blood tests and an MRI scan at QMC were negative, doctors decided not to proceed with further tests, including a lumbar puncture to analyse spinal fluid. This test may have revealed the autoimmune encephalitis. The jury found this failure to undertake a lumbar puncture meant potential indicators of the condition were missed.
Mia was transferred to the Becton Centre, a unit of Sheffield Children's Hospital, on 9 January 2024. She was found unresponsive in her room there just three weeks later, on 29 January.
Inadequate care and risk management
The jury delivered a narrative conclusion, highlighting multiple failings. They found that information passed between hospitals "provided an inappropriate level of assurance" that physical causes for Mia's psychosis had been ruled out.
Regarding the Becton Centre, the jury concluded: "Insufficiently robust communication and management of risk led to a failure to respond adequately to Mia's risk of self-harm." The jury acknowledged that the "rare presentation of a rare condition" posed complex challenges for diagnosis and care.
Senior coroner Tanyka Rawden recorded that Mia's cause of death was compression of the neck, caused by acute psychosis, caused by autoimmune encephalitis.
A mother's anguish and a call for change
In a powerful statement after the inquest, Mia's mother, Chloe Hayes, said her "beautiful little girl" had been "let down" when she needed specialist healthcare for the first time. "I will never forgive the Queen's Medical Centre or the Becton Centre for failing her," Mrs Hayes stated.
She believes her daughter was dismissed and passed to mental health services too quickly, and that the Becton Centre was "completely unsuitable" and failed to keep her safe. "I have never believed for a moment that Mia ever wanted to take her own life," Mrs Hayes added, describing Mia as a happy, fun, friendly girl with everything to live for.
Coroner Tanyka Rawden said she would be writing to Health Secretary Wes Streeting and professional bodies over concerns about the lack of national guidance for testing for autoimmune encephalitis.
Apologies and promised improvements
Dr Manjeet Shehmar, medical director at Nottingham University Hospitals NHS Trust, apologised to Mia's family. "We recognise that further testing may have had an impact on her future, for which we are truly sorry," she said.
Dr Jeff Perring, executive medical director at Sheffield Children's NHS Foundation Trust, also offered a deep apology and said changes had been made at the Becton Centre following a review. A Care Quality Commission inspection in September 2025 found the unit to be "safe" with "caring and responsive" staff.
Amy Rossall, the family's solicitor from Hudgell Solicitors, said the hope was that lessons learned from Mia's tragedy would help prevent other families from losing children to the same condition.
