• child psychiatry
• adolescent health
• ethics

An unfolding tragedy eclipsed by the pandemic has passed its most recent milestone. G was placed in foster care with her siblings when she was 4, living with them until the breakdown of her fostering arrangements in 2020, when she was 16. In January 2020, G started to harm herself to the extent that by October she had required 20 hospital admissions arising from the risk that she posed to herself. In May 2020, she was detained for assessment under the Mental Health Act (MHA) 1983. She was described as ‘incredibly complex, avoidant, very difficult to engage’; the psychiatrist considered that inpatient treatment was required, or in the absence of that, secure unit placement, ‘…at the very least a solo therapeutic bed provision’. Although the initial diagnosis was founded on post-traumatic stress disorder, subsequent assessments would reveal the development of an emerging personality disorder, rendering her vulnerable to self-harm.

At this stage, G was assessed as not meeting the requirements of a Tier 4 mental health admission.

Discharged from that detention after 28 days, she was placed in a residential placement where she was violent and aggressive to the staff, damaging property, applying effective ligatures to her neck and making many threats that she was going to kill herself. In the midst of this placement, punctuated by episodes of absconding and clinical assessments, she was again considered not to be suitable for a Tier 4 bed; rather, she was found to be mentally and medically fit to remain in the placement.

By the …