Coroner says NHS care not a factor in teen's death

The following report contains content about suicide that some readers may find distressing.

The actions of NHS staff did not contribute to the death of a teenage girl who took her own life, a coroner has concluded.

Ischia Montagu La Placa, 16, was found dead at her home in Lyme Regis, Dorset, on 16 February 2024.

An inquest in Bournemouth was told that Ischia, who had grown up in Henley-on-Thames, met NHS crisis workers in the weeks before her death but did not see a psychiatrist.

Dorset senior coroner Rachael Griffin said appropriate action had been taken by Dorset HealthCare University NHS Foundation Trust and that no act or omission by its employees contributed to Ischia's death. She recorded Ischia's death as a suicide.

The inquest heard that the teenager was admitted to hospital on 4 February 2024 and referred to a crisis service after being deemed to be at "medium risk".

Her case was escalated to the Core Child and Adolescent Mental Health Service (CAMHS) on 12 February after multiple self-harm incidents were reported.

The inquest heard access to a psychiatrist was not immediately discussed.

On 14 February, Ischia left a note and was reported missing before being found and returned home by police.

The inquest was told officers had no grounds to believe she was showing signs of mental disorder.

Ischia took her own life two days later.

Griffin thanked those who had assisted the investigation, including Ischia's family, who had shown "dignity and composure" throughout proceedings.

She finished by stating that Ischia had "made a huge difference to all those who knew her" during her short life.

In a statement before the inquest, her mother paid tribute to her "beautiful, fun, charismatic" daughter.

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