'Amazing' teen denied urgent mental health referral weeks before death

A smiling Emily Oakes-Buckingham

Emily Oakes-Buckingham, who died on January 8. - Credit: Oakes-Buckingham Family

An "amazing, kind and clever" teenager who died in tragic circumstances was refused an urgent referral by the region's mental health trust - despite her GP requesting one.

Emily Oakes-Buckingham died on January 8 in Addenbrookes' Hospital in Cambridge after an incident at home a week earlier on New Year's Day.

An inquest was held into her death on Friday at County Hall in Norwich.

Sprowston High School pupil Emily, 13, appeared to be full of life, conscientious and bright, always looking to help others and putting them before herself.

But beneath the surface, she had heartbreakingly dark moments of anxiety and fought severe mental health troubles, including self-doubt and an eating disorder.

However, ahead of the Covid-19 pandemic her mum Melanie, of Witard Road, Heartsease, described how she had "turned a corner" and was making real progress.

But once the country plunged into lockdown she began to struggle again - particularly during the second national lockdown towards the end of 2020.

Emily Oakes-Buckingham smiling wearing denim dungarees

Emily Oakes-Buckingham, from Heartsease. - Credit: Oakes-Buckingham family

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She found herself struggling to sleep and began to self-harm, leading her family to seek the help of her GP, who immediately referred her to the Norfolk and Suffolk NHS Foundation Trust.

The GP, Dr Ike Nnene of Thorpewood Medical Group told an inquest into her death that he had immediately made an urgent referral to the mental health services. 

He said she had told him enough to make him have serious enough concerns about her to request an urgent referral for mental health treatments - but this request was denied.

Instead, a clinician at the trust downgraded her referral, judging it not to be urgent.

Mrs Oakes-Buckingham, of Witard Road, questioned why the referral had been downgraded, while also criticising the fact that neither the GP or NSFT prescribed her medication to help her sleep.

Susan Stolworthy, operational manager with the Norfolk and Waveney community perinatal mental health

Susan Stolworthy, lead nurse for the Norfolk and Suffolk NHS Foundation Trust Photo: NSFT - Credit: NSFT

Susan Stolworthy, lead nurse for NSFT's child, families and young person service, said there should have been more conversations around Emily's downgrading before the decision was made, on June 5, the day after the referral was made.

She added: "I have concerns about how information was shared and that is feedback I can take back to the team."

She said that at the time the services were more "reactive" and that more onus was on families to alert them to changes of circumstances, but that action had been taken to address this following Emily's did.

Dr Nnene said that his guidelines were to be cautious with prescribing medication to help minors sleep - and that the urgent referral was the approach he saw as most appropriate - and that he believed it was needed.

Coroner Christopher Long gave a narrative conclusion and praised the amount of support she received from her immediate family - particularly her mother.

He said: "Emily was clearly in a very supportive family."

Speaking after the inquest, Mrs Oakes-Buckingham said her daughter was a "victim of Covid" having struggled so desperately with the lockdowns.

And paying tribute to her daughter, she spoke of her love of swimming, how highly thought of she was by her teachers and their unbreakable bond.

She said: "She was amazing - a force of nature. She was a competitive swimmer and a member of the City of Norwich Swimming Club, which she loved.

"On parents evening all of her teachers were fighting over her trying to get her to choose their courses for GCSEs and when they said she was a treasure they really meant it.

"She had really turned a corner before the pandemic hit, but she then just got so anxious about everything."

And Mrs Oakes-Buckingham also urged others to do what Emily did and make a parting gift of her organs - something her mum knew would be her wish.

She said: "I remember us talking about it once and she said: 'why wouldn't I want to donate my organs when I die, it's not like I'll need them'"

If you need help or support, contact the Samaritans on 116 123 or Norfolk and Suffolk Foundation Trust’s First Response helpline on 0808 196 3494 - both are available 24/7.