Inquest for Kate Savage
The issue
Petition for an Inquest into the Death of Kate Meron Savage 23/10/2006 - 23/7/2020.
My daughter Kate was only 13 when she died. She suffered with what we loosely term 'mental illness' or is perhaps more correctly known as a brain disease. This brain disease caused intrusive, repetitive thoughts and intense periods of mania and depression. These thoughts centred around having to die.
My daughter repeatedly told us and the staff at CAMHS and PCH that she did not want to die, but the thoughts were too big for her to control. That she knew she was safe in the hospital where she had no way for the thoughts to make her kill herself, but when she was home she couldn't fight them, no matter how hard she tried. And she did try.
Kate was an amazing, talented girl with her whole life ahead of her. We had chosen paint to redecorate her bedroom. She had picked out new furniture and accessories to create a nature theme. She was an expressive, independent person who had a few piercings and plans for more as rewards for staying out of hospital. As rewards for fighting against her disease and staying alive. She had picked out a beautiful rainbow ombre hair style which would have been her reward for staying alive for 3 weeks. She desperately wanted it. But she couldn't fight the illness for long enough. It was like trying to reward a cancer patient for staying alive - it was beyond her control. She dreamed of working with wildlife rescue and was waiting for her 15th birthday so she would be allowed to volunteer. Her 15th birthday passed almost a month ago. She had already been gone for over a year and I spent the day reading through the medical records of her last few weeks alive.
I have spent the time from July 2021 to October 2021, between the anniversaries of her death and her birth, going through her medical records. And what I found has only added to my trauma, grief and anger.
Although I cannot go into too much detail for legal reasons, some of the glaring issues I found are as follows:
1. Significant differences between what Kate and I reported after each suicide attempt, and what was recorded in her notes.
2. Diagnoses which were made based on assumptions made about how Kate was raised, which were not discussed with the family and could easily have been demonstrated to be false if they had been.
3. Little to no record of the descriptions we as parents gave of Kate's symptoms over the two years prior to her first hospital admission, including what we described as a clear manic episode and an extended depressed episode. We were very familiar with the symptoms of these due to Kate's father having bipolar 1.
4. Little to no record of the descriptions we gave of Kate's OCD behaviours.
5. Incorrect medication records, which were still incorrect until the day she died, despite the hospital being repeatedly told of the error. They incorrectly recorded that Kate had been trialled on a mood stabiliser and that it had been unsuccessful and then ceased. This had never happened. This may have impacted on the diagnostic decision that a mood stabiliser would not be successful.
6. Kate's first admission to hospital was due to suicidal thoughts and actions from many months of severe depression and being unable to leave the house due to her irrational belief that she was hugely obese and everyone would stare at her. During this admission in a mental health ward as a suicidal child, the hospital sent in a dietician and an exercise physiologist. They informed Kate that she was obese according to her BMI (Kate was very broad shouldered and heavy boned and had also put on some weight during her extended period of being housebound) and told her she needed to diet and exercise. When Kate came home she informed us that the hospital had confirmed that she was obese, that it was all true. And since she couldn't lose weight, she may as well be dead.
7. Frequently being given access to sharps on the mental health 'secure' ward despite the hospital being aware she would self harm with any sharp object. The hospital failed to follow their own procedures regarding checking Kate for sharps on entry to the ward, leading to a potentially fatal incident where she had taken the blades off a sharpener at home and hidden it on her body and attempted to cut her throat on the ward. Another patient alerted staff as she was not being supervised at the time. The in-hospital school staff failed to account for all scissors which were given to the children, leaving Kate with a pair of scissors she used to self harm for several days on the ward, with no-one supervising her or noticing the new self harm marks. Failing to account for cutlery on the ward and leaving Kate alone, unsupervised in her room when she was extremely distressed to cut herself on the bathroom floor.
8. The hospital gave Kate a medication which the parents had previously stated had increased her suicidal thoughts and given her nightmares. They refused to cease this medication despite parent requests and steadily increased it as her suicidal thoughts and actions grew more acute.
9. The hospital gave Kate a valium type drug when she was distressed on the ward in order to calm her down. They did not inform the parents that the medication had been given, did not mention it on any of her discharge notes and did not give the parents the option of having this medication at home. Instead they stated that as Kate was calm on the ward and became distressed at home, there must be something happening at home causing her distress.
10. The hospital informed Kate that if her suicide attempts continued, DCP would become involved and possibly have to remove her younger sister from our home due to the danger Kate posed. Kate was aware that her sister suffered from anxiety and OCD and had never spent a night away from home before. Kate had long been her sister's defender and loved her above all else. This convinced Kate that, as she couldn't control her suicidal impulses, her family would be better off if she was dead.
11. The hospital ignored the previous suggestion by a pre-eminent private psychiatrist that Kate had early stages of bipolar disorder.
For all these reasons and more, we would like to see a full independent inquiry and/or an inquest into our daughter's death. There are other children being treated right now in the same way that our daughter was treated. Only a full investigation would enable necessary changes to save other children's lives.
22,353
The issue
Petition for an Inquest into the Death of Kate Meron Savage 23/10/2006 - 23/7/2020.
My daughter Kate was only 13 when she died. She suffered with what we loosely term 'mental illness' or is perhaps more correctly known as a brain disease. This brain disease caused intrusive, repetitive thoughts and intense periods of mania and depression. These thoughts centred around having to die.
My daughter repeatedly told us and the staff at CAMHS and PCH that she did not want to die, but the thoughts were too big for her to control. That she knew she was safe in the hospital where she had no way for the thoughts to make her kill herself, but when she was home she couldn't fight them, no matter how hard she tried. And she did try.
Kate was an amazing, talented girl with her whole life ahead of her. We had chosen paint to redecorate her bedroom. She had picked out new furniture and accessories to create a nature theme. She was an expressive, independent person who had a few piercings and plans for more as rewards for staying out of hospital. As rewards for fighting against her disease and staying alive. She had picked out a beautiful rainbow ombre hair style which would have been her reward for staying alive for 3 weeks. She desperately wanted it. But she couldn't fight the illness for long enough. It was like trying to reward a cancer patient for staying alive - it was beyond her control. She dreamed of working with wildlife rescue and was waiting for her 15th birthday so she would be allowed to volunteer. Her 15th birthday passed almost a month ago. She had already been gone for over a year and I spent the day reading through the medical records of her last few weeks alive.
I have spent the time from July 2021 to October 2021, between the anniversaries of her death and her birth, going through her medical records. And what I found has only added to my trauma, grief and anger.
Although I cannot go into too much detail for legal reasons, some of the glaring issues I found are as follows:
1. Significant differences between what Kate and I reported after each suicide attempt, and what was recorded in her notes.
2. Diagnoses which were made based on assumptions made about how Kate was raised, which were not discussed with the family and could easily have been demonstrated to be false if they had been.
3. Little to no record of the descriptions we as parents gave of Kate's symptoms over the two years prior to her first hospital admission, including what we described as a clear manic episode and an extended depressed episode. We were very familiar with the symptoms of these due to Kate's father having bipolar 1.
4. Little to no record of the descriptions we gave of Kate's OCD behaviours.
5. Incorrect medication records, which were still incorrect until the day she died, despite the hospital being repeatedly told of the error. They incorrectly recorded that Kate had been trialled on a mood stabiliser and that it had been unsuccessful and then ceased. This had never happened. This may have impacted on the diagnostic decision that a mood stabiliser would not be successful.
6. Kate's first admission to hospital was due to suicidal thoughts and actions from many months of severe depression and being unable to leave the house due to her irrational belief that she was hugely obese and everyone would stare at her. During this admission in a mental health ward as a suicidal child, the hospital sent in a dietician and an exercise physiologist. They informed Kate that she was obese according to her BMI (Kate was very broad shouldered and heavy boned and had also put on some weight during her extended period of being housebound) and told her she needed to diet and exercise. When Kate came home she informed us that the hospital had confirmed that she was obese, that it was all true. And since she couldn't lose weight, she may as well be dead.
7. Frequently being given access to sharps on the mental health 'secure' ward despite the hospital being aware she would self harm with any sharp object. The hospital failed to follow their own procedures regarding checking Kate for sharps on entry to the ward, leading to a potentially fatal incident where she had taken the blades off a sharpener at home and hidden it on her body and attempted to cut her throat on the ward. Another patient alerted staff as she was not being supervised at the time. The in-hospital school staff failed to account for all scissors which were given to the children, leaving Kate with a pair of scissors she used to self harm for several days on the ward, with no-one supervising her or noticing the new self harm marks. Failing to account for cutlery on the ward and leaving Kate alone, unsupervised in her room when she was extremely distressed to cut herself on the bathroom floor.
8. The hospital gave Kate a medication which the parents had previously stated had increased her suicidal thoughts and given her nightmares. They refused to cease this medication despite parent requests and steadily increased it as her suicidal thoughts and actions grew more acute.
9. The hospital gave Kate a valium type drug when she was distressed on the ward in order to calm her down. They did not inform the parents that the medication had been given, did not mention it on any of her discharge notes and did not give the parents the option of having this medication at home. Instead they stated that as Kate was calm on the ward and became distressed at home, there must be something happening at home causing her distress.
10. The hospital informed Kate that if her suicide attempts continued, DCP would become involved and possibly have to remove her younger sister from our home due to the danger Kate posed. Kate was aware that her sister suffered from anxiety and OCD and had never spent a night away from home before. Kate had long been her sister's defender and loved her above all else. This convinced Kate that, as she couldn't control her suicidal impulses, her family would be better off if she was dead.
11. The hospital ignored the previous suggestion by a pre-eminent private psychiatrist that Kate had early stages of bipolar disorder.
For all these reasons and more, we would like to see a full independent inquiry and/or an inquest into our daughter's death. There are other children being treated right now in the same way that our daughter was treated. Only a full investigation would enable necessary changes to save other children's lives.
The Decision Makers
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Petition created on 18 November 2021