Overview
- A consultant testified that an early‑hours ligature incident on January 29 was not passed on at the morning handover, saying the team would have reconsidered their approach had they known.
- Clinicians said Mia tied ligatures on four known occasions at the Becton Centre, with staff noting some were shown to them as cries for help and that her distress could switch rapidly.
- Observation levels were reduced from one‑to‑one and hourly overnight checks to 15‑minute rounds after staff reported the constant monitoring unsettled her, according to inquest evidence.
- Mia was transferred to the Becton Centre on January 9 because few units accept under‑13s, and earlier tests in Nottingham, including an MRI, had not identified a physical cause for her presentation.
- She was found unresponsive in her room on January 29 and died the next day, and the 10‑day inquest is examining her placement, risk assessments, staffing pressures and how self‑harm incidents were documented.