Ashtons Legal secures settlement for family of Madie Savory after hospital death

Amanda Cavanagh, Medical Negligence specialist at Ashtons Legal, achieved a settlement for the family of Madeleine Savory (Madie), who tragically died following an act of self-ligature on 19 February 2022 whilst an in-patient at Ipswich Hospital. Madie was 15 years old at the time of their death.

Madie had a significant history of periodic suicidal ideation and self-harm, which was known to the Child and Young Persons Mental Health Service and Ipswich Hospital. Madie had been hospitalised following an act of self-harm on 3 February 2022 and remained in Ipswich Hospital awaiting allocation of a Tier 4 bed in a paediatric mental health ward. They were assessed to be at a high risk of self-harm. A risk assessment on 12 February 2022 identified a need for additional measures to manage their risk, which included mental health observations. However, observations ceased around 14 February 2022 without any clear rationale. On 19 February 2022, Madie walked into the bathroom unobserved. The specific risk the bathroom posed had not been communicated to staff, who entered around 15 minutes later to discover that Madie had self-ligatured.

A ten-day inquest was held at Ipswich Coroner’s Court in August 2023. The Coroner gave a narrative conclusion, which identified, amongst other failures by the Trust, a failure to implement relevant policies that specifically dealt with the management of children like Madie. The Coroner held that this failure “probably more than minimally” contributed to Madie’s death. The Coroner issued a Prevention of Future Deaths report on 15 November 2023.

A claim was brought under the Fatal Accidents Act 1976 and the Human Rights Act 1998. A settlement was reached without the Trust making admissions of liability, and Court approval in respect of Madie’s sibling’s claim was obtained at an Infant Approval Hearing in January 2025.

Amanda Cavanagh comments: “Madie’s parents did everything within their power to keep Madie safe, only to be let down by a system unfit for purpose. Following their tragic death, Madie’s parents faced another battle to find out what went wrong. By exposing the failures, the hope is that no other child will lose their life, and no other family will live through the pain they continue to endure. Madie’s parents behaved with determination and dignity throughout the process.”

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