"IT IS sadly too little, too late for Mazie."

That was the message from a public law expert acting on behalf of the family of a 14-year-old girl at the conclusion of an inquest into her tragic death.

Chris Callender said the family of Maziellie Mackenzie, known as Mazie, hoped her death could be a 'catalyst for change'.

Mazie, from Barrow, was found hanged in woodland near Heysham Barrows, Lancashire, on June 23, 2018.

Mazie had an extensive history of self-harm and had previously disclosed that she had been the victim of sexual abuse.

At the time of her death, she was a resident of The Cove in Heysham. This is a hospital for young people between the ages of 13 and 18 who are experiencing a variety of mental health problems.

An inquest into her death, which concluded at Preston Coroner’s Court on Friday, recorded a verdict of death by suicide.

The inquest also found that Lancashire Care NHS Foundation Trust failed to revisit her formulation and risk management plans when self-harm incidents occurred, and did not include Mazie’s needs and how they were to be met.

Mr Callender said: "This is a truly tragic case which resulted in the death of a vulnerable young girl who was in desperate need of care, support and protection.

“As was detailed throughout the inquest, Mazie had a long history of self-harm behaviour. She was also a flight risk, having run away more than 20 times in less than a year from the care home where she had been living prior to moving to The Cove.

“Despite this, there was countless evidence to suggest that more could have been done to protect her.

"Better communication between the relevant safeguarding authorities, more comprehensive risk assessments, and more appropriate supervision.

“The coroner’s findings show that, had there been robust procedures in place and more staff at the time, then Mazie’s death could possibly have been avoided.

“While it is evident that lessons have been learnt from this terrible tragedy, it is sadly too little, too late for Mazie."

The inquest also concluded that:

  • Mazie's risk assessment held limited risk history and management plans in regard to her risk of going missing.
  • There was no written standardised procedure for agreeing and facilitating leave.
  • Communication of relevant information and record-keeping did not meet the required standard.
  • There were insufficient staff to supervise children when on leave from the hospital.

The coroner further concluded that, with regard to York Child and Adolescent Mental Health Services (CAMHS), which had also dealt with Mazie during her life:

  • There was a delay in making a referral to place Mazie in a tier-4 placement, which was appropriate for her needs.
  • There was a failure by York CAMHS to accept ownership of her case and that, during that delay, Maize’s mental health deteriorated.