After Mia had been admitted to the Becton Centre, staff decided that during the day she would be on 15 minute “arm’s length” observations at all times – where a member of staff was with her constantly.
But she found it “unendurable” and highly intrusive, Dr Lavelle, from Sheffield Children’s NHS Foundation Trust, said.
During the night, Mia was also checked on hourly.
The daytime observations seemed to exacerbate Mia’s condition, Dr Lavelle said, so the aim was to reduce them if the girl’s behaviour settled and she developed relationships with staff.
She was at times “lively and full of life” and engaged with lessons, but her behaviour was “changeable” and she could become “frustrated and cross”, especially at being observed so closely, Dr Lavelle said.
Mia tried to harm herself on at least four separate occasions during her time at the facility but told staff what she was doing and Dr Lavelle said: “She was telling us she needed extra support.”
Mia’s last incident of self harm took place in the early morning of 29 January but it was not noted in the staff handover.
When asked if extra steps would have been taken to monitor Mia if she had known about the incident, Dr Lavelle said: “It is impossible to answer but I have asked myself that question more times than I can tell you.
“But on balance, Mia did not come across as someone who wanted to end her own life.”