A coroner has written to NHS England and the health secretary sharing his concerns after a 15-year-old took their own life in a Suffolk hospital.

Madeleine Savory, who identified as non-binary and used they/them pronouns, was admitted to the Bergholt Ward, a paediatric ward at East Suffolk and North Essex NHS Foundation Trust (ESNFT) run Ipswich Hospital, on February 3, 2022, after they absconded from Northgate High School and self-harmed.

They were placed on a list for a 'tier 4' bed in a mental health unit on February 7 but, on February 19, they made an attempt on their life while in the ward toilet, and died on February 26.

Madeleine had a five-month history of self-harm, low mood, food restriction and gender dysphoria and had been under the care of Norfolk & Suffolk NHS Foundation Trust (NSFT) after a hospital admission in September 2021.

They had been on the ward for 12 days before the attempt on their own life, and the average wait for a mental health bed in February 2022 was around 46 days.

During an inquest, which took place in August, coroner Darren Stewart said the lack of appropriate resources surrounding mental health beds may have contributed to Madeleine's death, although he found the East of England Provider Collaborative (EEPC) who manage bed allocation in the area were "diligent" and did everything they could at the time.

In a Prevention of Future Deaths report addressed to health secretary Victoria Atkins and NHS England, coroner Stewart said he was satisfied with the measures both ESNEFT and Northgate High School have put in place since the incident to address the failures identified in the inquest. 

He raised concerns around the national availability of tier 4 beds in paediatric mental health facilities to allow for timely allocation for children, such as Madeleine, who need specialist care.

He said: "In my opinion there is a risk that future deaths could occur unless action is taken."

NHS England and the health secretary now have a duty to respond to the report by January 10. 

After the conclusion of the inquest, Rowena Mackie, headteacher at Northgate High School, said: "We miss Madie very much and their loss has been felt across the school community.

"We acknowledge the coroner’s conclusion and as presented at the inquest we acted swiftly to review all our safeguarding arrangements. We have implemented several changes as a result.

"Our thoughts are with Madie’s family during what we know must be a very difficult time."

Dr Angela Tillett, chief medical officer at East Suffolk and North Essex NHS Foundation Trust, said: “Everyone involved with Maddie’s care is deeply saddened by the tragic event.

"We have made significant changes into how we care for young people with mental health issues since 2022 and remain committed to working in close partnership with our mental health colleagues.

"We offer our deepest sympathy and condolences to Maddie’s family.”

NHS England has been approached for comment.