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16-year-old Evelin Chacko found dead near hospital just ‘an hour after leaving’, inquest hears

It was advised that NHS staff should 'monitor' her not long before she left the hospital.

Danny Jones - 11th August 2023

Following an inquest into the death of teenager, Evelin Chacko, Bolton Coroners’ Court heard that the 16-year-old was found dead in a nearby woodland just an hour after leaving the hospital and that there were “systemic failures” at “every stage” of her treatment.

Evelin Chacko, from Farnworth, was admitted to Royal Bolton Hospital following an overdose at her family home on 1 July 2020 and, after being initially taken into A&E, was placed in C2 ward: an adult treatment centre for people with complex care needs and the elderly.

Bolton Coroners’ Court heard how Evelin left the ward and returned home on at least three occasions but had always come back, with C2 consultant Dr Geraldine Donnelly confirming it was an open ward and that Evelin was “free to come and go” without monitoring from July 5 onwards.

However, after a meeting on July 10, where the assigned nurse Afreen Khan was said to be awaiting a mental health review for Evelin, he was told the next steps would be dealt with by another team and was not made aware that she attempted to harm herself the night before her death during the handover.

The inquest also heard that a mental health review took place on July 13 at around 1pm but Mr Khan was not able to attend due to his workload and the pressures of looking after nine other patients. Evelin left at 2.12pm and died just over an hour later.

Mr Khan told the court that “you shouldn’t be a named nurse and in charge [of multiple others], but we were expected to do both roles because of the pandemic and staffing. I didn’t have the chance to sit down and read her notes. I gave her medication, carried out observations and saw her behaviour.”

After hearing that she was placed on an “inappropriate ward” and should have been afforded “extra contact to check she was ok”, Area Coroner Professor Dr Alan Walsh also questioned how Khan could have been able to do “two jobs at once” in attending to the other patients and keeping an eye on Evelin.

Another staff member, Mary Hart, worked various shifts throughout Ms Chacko’s time in the hospital and said that while she had no immediate concerns about her wellbeing, she did note how “Evelin walked past and she appeared to be very upset” on 13 July, adding that “it was out of character for her.”

However, it is worth noting that although Evelin was described as a “smiley” individual by both her family and individuals around the hospital, it was also heard that she had a long history of “suicidal ideation” and had been escorted away from a motorway bridge in May earlier that year.

Data extracted from her phone also showed that in the months leading up to her death, the 16-year-old’s internet searches included, ‘I feel like I have to commit suicide’, ‘How to hide that I am suicidal’, and ‘What to write in a suicide note’, as well as googling hanging methods on the day she died.

Giving evidence in the inquest, Dr Patrick Waugh’s examination of her body showed ligature marks, as well as abrasions on her chin which suggested an attempt to adjust/struggle and suggested hanging as the cause of death.

Noticing that she was crying, Hart said she tried to approach the teen and although she did speak to her, Evelin “wouldn’t engage or acknowledge.” After returning from the Clinical Decision Unit, another nurse, Dawn Murphy, said she met security at the entrance and gave Evelin’s name and description.

It was then heard that in the notes entered into the electronic system at 1.49pm following the mental health review, it was stated that there was a “need to monitor” her but — similarly to Mr Khan and Evelin’s attempt to harm herself — she was not made aware of the contents of the report.

Speaking on behalf of the Chacko family, a spokesperson for Oakwood Solicitors said: “We are deeply saddened by Evelin Chacko’s tragic death however, we are consoled with the admissions made by Bolton NHS Foundation Trust in relation to their failings.

“The investigations are still underway with regards to the involvement of Greater Manchester Mental Health and Bolton Council, but it has been recognised that Evelin, a 16-year-old, was on a wholly inappropriate adult acute ward. There is a lot to learn from her death.

“The nurse involved in Evelin’s care admitted that they did not have time to review the records and she was inappropriately placed on a ward where they were not experienced to deal with Evelin’s mental health. What was consistent is that Evelin was loving and caring.”

The inquest has now been halted until 30 October when more evidence will be presented to the Coroners’ Court. Oakwood concluded by stating, “It is hoped that when the investigations resume in the Autumn that the family will be able to receive some closure.”

For anyone struggling with mental health, don’t hesitate to get in touch with the Samaritans on 116 123, text ‘SHOUT’ to 85258, contact the NHS on 101 or, if it’s an emergency, call 999 immediately.

You can also find helpful resources regarding sexual abuse support HERE.

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