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Jury finds failures in mental health care of 17 year old Lucy Curtis

Lucy Curtis was 17 years old when she died in hospital, following an incident of self-harm at the Riverside Adolescent Mental Health Unit in Bristol. An inquest into her death commenced on 22 June 2026 at Avon Coroner’s Court. Over the course of a three-week inquest, a jury heard evidence that Lucy’s contact with mental health services began in January 2023, when she sought help for anxiety, low mood and self-harm. Despite multiple referrals to Child and Adolescent Mental Health Services (CAMHS), Lucy waited several months before receiving specialist support, during which time her mental health deteriorated and she experienced increasing thoughts of ending her life. Lucy was eventually accepted into CAMHS in August 2023, but following a serious deterioration in her presentation she was admitted to Wessex House, an inpatient mental health unit in Bridgwater, later that month.

The inquest heard evidence about Lucy’s experiences during her admission to Wessex House, including serious incidents of self-harm, concerns about periods of unsupervised leave, and the circumstances surrounding her discharge home in November 2023. After a further deterioration in her mental health, Lucy was admitted to the Riverside Unit in Bristol on 12 December 2023. The jury heard evidence about the challenges in managing Lucy’s escalating risk during this admission, including decisions around observations, whether Lucy should have been assessed under the Mental Health Act, and the events leading up to 27 December 2023, when Lucy was found unresponsive following a further episode of self-harm.

On 10 July 2026, the jury returned a narrative conclusion identifying a number of failures and missed opportunities that probably or possibly contributed to Lucy's death:

  • The delay in direct engagement and acceptance onto CAMHS caseload meant that help was not available to Lucy until her decline was already advanced. This possibly contributed to Lucy’s death.
  • The effectiveness and communication about discharge from Wessex House, and the uncertainty caused by the process by which the discharge date was changed has been described as a turning point in Lucy’s mental health. For this reason, there was a possible contribution to Lucy’s death. 
  • The failure of Riverside to recognise the escalating situation (including concealment of ligatures and increasing intensity and frequency of self harm episodes, indicating increased risk) on 26th and 27th December 2023, and the subsequent failure to implement adequate observation levels (in line with previous occurrences) probably contributed to Lucy’s death. 
  • Given the uncertainty over the precise time Lucy applied the fatal ligature, we find that the failure of Riverside to adhere to Lucy’s observation levels on the morning of 27th December possibly contributed to Lucy’s death. 
  • The time lost, due to various factors, in the delivery of emergency treatment until the arrival of paramedics possibly contributed to Lucy’s death.  

The family was represented by Jamie Burton KC and Ruby Peacock, instructed by Amy Ooi of Bhatt Murphy solicitors. 

A copy of the family’s statement following the inquest can be viewed here.

See here for further details of the evidence given during the inquest. The inquest and the circumstances of Lucy’s death have been widely reported: 

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