Fourteen-year-old Ruth Szymankiewicz was supposed to be safe. She was in a psychiatric intensive care unit, admitted for treatment of an eating disorder and under orders for round-the-clock supervision. Yet on Feb. 12, 2022, she was left alone for about 15 minutes at Huntercombe Hospital in Maidenhead, England — and in that short time, she fatally harmed herself.

An inquest jury at Buckinghamshire Coroner’s Court has now concluded Ruth was unlawfully killed. Unfortunately this ruling is more than two years late, which shows just how mixed up a system ostensibly created to protect children failed this girl at every chance.

Ruth’s parents, Kate and Mark Szymankiewicz, had turned to the hospital for help when their daughter needed the most intensive care available. Instead, they said, she was “locked away and harmed” by the very system meant to keep her safe.

The night she sustained her fatal injuries, CCTV showed Ruth with her assigned support worker, a man identified as Ebo Achempong, in the unit’s television room. Achempong — who had been hired by an agency using a false name and fake documents — repeatedly left her alone despite the requirement for constant observation. When he left the room for the last time, Ruth returned to her bedroom. She was found gravely injured shortly after.

Achempong has reportedly returned to Ghana. The inquest also heard that the unit was chronically understaffed, with half the workers on duty that day employed through agencies. Staff training was inconsistent, and Ruth had not been prevented from accessing harmful content online. Visiting rules allowed only one family member at a time, limiting her contact with her support network.

Huntercombe Hospital was already under scrutiny. The Care Quality Commission rated it “inadequate” in early 2021 and “requires improvement” later that year. But those warnings did little to change the outcome for Ruth. The facility has since been permanently closed.

The Department of Health and Social Care called the case “shocking” and acknowledged that care “fell far below the standards we expect.” Officials pointed to new investments aimed at expanding mental health bed availability and reducing the need for patients to be sent far from home for treatment.

Active Care Group, which ran the hospital, expressed condolences and said it has since severed ties with the agency that hired Achempong. “The safety and wellbeing of those we support must never be compromised,” the company said, adding that it has made “significant improvements” in recent years.

For Ruth’s family, those words are cold comfort. “There is an empty space at our table, a silent bedroom in our home and a gaping hole in our family that will never be filled,” her mother said.

The jury’s conclusion leaves no doubt: Ruth’s death was preventable. What remains is the question of whether the system will change enough to prevent it from happening again.