The tragic death of 14-year-old Ruth Szymankiewicz has brought into sharp focus the serious failings within children’s mental health care in the UK. Ruth, a teenager struggling with an eating disorder, was under treatment at Huntercombe Hospital in Berkshire.
Despite being placed on strict one-to-one observation due to her vulnerability, she was left alone by an agency worker using a false identity. This lapse ultimately led to her death, which a jury at Buckinghamshire Coroner’s Court has now ruled as unlawful killing. Her parents, Mark and Kate Szymankiewicz, have described the systemic failures that contributed to this devastating outcome.
They explained that while seeking help, they found themselves “trapped in a system that was meant to care for her but instead locked her away and harmed her.” Their heartfelt statements underscore the emotional and procedural shortcomings within the hospital system, highlighting issues of staffing, inadequate supervision, and lack of family involvement in critical decisions.
Background of Ruth’s Treatment at Huntercombe Hospital
Ruth Szymankiewicz had been admitted to Huntercombe Hospital’s Thames ward, a psychiatric intensive care unit, for treatment of her eating disorder. Due to her history of self-harm, she was placed under a “level three observation” plan, which required constant supervision. Despite these precautions, on February 12, 2022, she was left unsupervised by Ebo Acheampong, an agency worker who had never worked in a psychiatric hospital before.
Acheampong had been hired by Platinum agency using a false identity and had only joined Huntercombe Hospital for his first shift that day. Originally assigned to a different ward, he was asked to assist on Thames ward due to severe staff shortages, which already meant nurses could not take their breaks.
The ward was missing at least half of its staff that day, further increasing the risk to patients. This situation exposed Ruth to harm, as the staff member responsible for watching her repeatedly left the room, eventually allowing her to walk to her bedroom and self-harm, resulting in her death two days later at John Radcliffe Hospital in Oxford.
BREAKING: The parents of Ruth Szymankiewicz speak after her death on a children's mental health ward was ruled an unlawful killing.
— Sky News (@SkyNews) August 14, 2025
The 14-year-old was left unsupervised by an agency worker who was using a fake ID at Taplow Manor in Berkshire.https://t.co/TC2ROCL7wW pic.twitter.com/dXmQMKX8ST
The hospital’s environment and procedures were found to be insufficient for her needs. Prior to her admission, Huntercombe Hospital had been rated “overall inadequate” by the Care Quality Commission in February 2021. Concerns had already been raised about the ward’s ability to monitor patients requiring special observation due to staffing issues. Despite warnings from experienced staff members, such as support worker Michelle Hancey, these concerns were not adequately addressed.
Systemic Failures and Inadequate Care
The inquest highlighted several systemic failures at Huntercombe Hospital that contributed to Ruth Szymankiewicz’s death. Firstly, the hospital allowed an untrained agency worker to supervise a highly vulnerable patient. The worker, using a false identity, had no prior experience in psychiatric care. This points to major lapses in the recruitment and verification process of staff, which are fundamental to patient safety in mental health facilities.
Secondly, the ward’s staffing shortages meant that patients like Ruth were left at serious risk. The combination of insufficient permanent staff and reliance on temporary workers created a fragile system that could not guarantee the safety of patients under observation. The inquest revealed that Ruth Szymankiewicz’s responsible clinician had already deemed the ward unsuitable for her recovery, indicating that her care pathway was fundamentally flawed from the start.
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Ruth Szymankiewicz’s parents were also excluded from critical decisions about her care and were not provided adequate information regarding appeal processes and refusal rights. The family emphasized that their daughter was isolated, scared, and alone, highlighting the emotional neglect alongside the procedural failures. The inquest also revealed that Ruth had access to restricted material that could be used to self-harm, showing further lapses in monitoring and safety protocols.
CCTV footage presented during the inquest depicted the agency worker leaving Ruth unsupervised in the ward lounge. Initially for brief moments and then for longer periods, these lapses allowed Ruth the opportunity to enter her bedroom and self-harm without intervention. The footage underscored the extreme consequences of even short-term lapses in supervision, particularly for a vulnerable child on level three observation.
Impact on Family and Broader Mental Health Services
Mark and Kate Szymankiewicz spoke openly about the devastating impact of Ruth’s death on their family and the need for systemic change. They highlighted that Ruth’s case is not isolated and could happen to any child, pointing to broader failures within mental health services for children. Their statements emphasized the urgent need for adequate staffing, better training, transparent care pathways, and active family involvement to prevent similar tragedies.
The inquest’s conclusion of unlawful killing not only acknowledged the preventable nature of Ruth’s death but also drew attention to the critical gaps in mental health care. The agency worker, Ebo Acheampong, fled the UK for Ghana and never returned to Huntercombe Hospital. His actions, combined with the hospital’s prior inadequacies and poor oversight, created a perfect storm that resulted in a preventable loss of life.
Huntercombe Hospital, which was owned by Active Care Group at the time, has since closed the facility. A spokesperson from Active Care Group expressed condolences to Ruth’s family and emphasized their commitment to improving care standards and learning lessons from the incident. However, the family and the wider public view this as a reactive response, highlighting the need for proactive systemic reform in children’s mental health services.
The case also underscores the importance of regulatory oversight. The Care Quality Commission had previously inspected the hospital, but the failures persisted despite warnings. This situation raises questions about the effectiveness of inspections and enforcement actions in ensuring patient safety.
Lessons and Call for Reform
Ruth Szymankiewicz’s death serves as a stark reminder of the human cost of systemic failures in mental health care. It emphasizes the need for rigorous staff recruitment processes, thorough background checks, and proper training for anyone entrusted with vulnerable patients. Staffing levels must be adequate to meet the demands of intensive care units, and temporary or agency workers should never be placed in situations where patients’ lives are at risk without proper support.
The tragedy also highlights the necessity of involving families in care decisions and maintaining clear communication about treatment pathways and patients’ rights. Families provide essential insight into a patient’s history and needs, and their exclusion can have devastating consequences. In Ruth’s case, exclusion from her care compounded her vulnerability, leaving her isolated at a critical time.
Furthermore, hospitals must ensure strict monitoring of patients at risk of self-harm, including restricted access to harmful materials and active supervision in line with observation levels. Technology such as CCTV can support safety measures but cannot replace trained staff and proper protocols. Every patient must be treated as an individual with tailored safeguards, particularly those in psychiatric intensive care.
The wider mental health system must learn from Ruth’s death to prevent similar incidents. Policies regarding agency staffing, emergency response, and ward safety must be reviewed and strengthened. Regulatory bodies like the Care Quality Commission need to take proactive steps to ensure hospitals are adhering to safety standards and addressing prior inspection concerns effectively.
Ruth’s parents have expressed hope that sharing her story will inspire change in children’s mental health services. Their advocacy shines a light on the need for accountability, systemic reform, and a culture that prioritizes patient safety above operational convenience. Mental health services must evolve to ensure that children in their care are supported, monitored, and protected at all times.
The unlawful death of Ruth Szymankiewicz is a tragedy that reflects systemic weaknesses in children’s mental health services. The combination of staffing shortages, inadequate supervision, unverified agency workers, and insufficient family involvement created conditions that led to a preventable loss of life.
Ruth’s story is a call to action for policymakers, healthcare providers, and regulators to ensure that such a tragedy never occurs again. Only through meaningful reform, proper oversight, and a commitment to safeguarding vulnerable patients can the mental health system begin to restore trust and truly protect those it serves.
This heartbreaking case reminds us that children in mental health care require vigilance, compassion, and robust systems designed to prevent harm. Ruth’s life and her family’s pain should serve as a catalyst for comprehensive improvements, safeguarding future generations from preventable tragedies in mental health institutions.