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Inquest Finds Missed Test and Safeguarding Failures May Have Led to Mia Lucas’s Death

The case exposed a rare, treatable brain inflammation that can first appear as psychosis in children.

Overview

  • A Sheffield jury said Nottingham’s QMC not performing a lumbar puncture before transfer and weak risk management at Sheffield’s Becton Centre possibly contributed to the 12-year-old’s death.
  • Post-mortem results disclosed during the hearing identified autoimmune encephalitis as the condition underlying her acute psychosis.
  • Nottingham University Hospitals apologised and said lumbar punctures will be performed in all suspected cases, with strengthened staff training and guidance.
  • Sheffield Children’s NHS Foundation Trust expressed sorrow, detailed changes at the Becton Centre, and noted a recent CQC inspection finding the unit safe and responsive.
  • The senior coroner said she will write to the health secretary and professional bodies about the absence of national guidance on testing for autoimmune encephalitis.