A new report is to be produced into the deaths of three young people at the same mental health unit.
Rowan Thompson, 18, died at the Prestwich Mental Health Unit, Bury, in October 2020, followed by Charlie Millers, 17, in December that year, and Ania Sohail, 21, in June last year.
Now the hospital’s trust, Greater Manchester Mental Health NHS Foundation Trust, is to commission an ‘external report’ to which NHS England will have input in deciding its terms of reference.
The plan has been criticized by Charlie’s mother, Samantha Millers, and Rowan’s father, Marc Thompson, who have called for NHS England to conduct their own investigation.
The grieving parents, who say observation practices at Prestwich need to be improved, do not accept NHS England and the hospital trust’s assurances that the report will be ‘independent’.
Observations are checked by staff on in-patients to confirm their safety, carried out continuously or at specific intervals, such as every five, 10 or 15 minutes.
Charlie Millers, who had a history of self-harm and receiving in-patient treatment, was found unresponsive in his room in the Junction 17 wing of Prestwich Hospital on December 2, 2020. He was given CPR at the scene and taken to Salford Royal Hospital but died five days later.
Serious Incident Review done by the trust said that Charlie was seen with ligatures around his neck three times in the hours before he was found unresponsive with a ligature around his neck.
The review says he was alone at the time when he was found unresponsive in his room.
Charlie’s mother told the MEN that she was told her son was being checked on once every five minutes at the time he was fatally injured. She believes he should not have been left alone at all at the time.
He had previously had one-to-one monitoring because of his history of self-harm and attempts on his own life, the review says.
It reveals that at the time he was found unresponsive he had only been back at the unit for two-and-a-half hours, after having been on home leave.
An inquest was due to open on February 28 into Charlie’s death but it has now been adjourned by the Coroner to a later date in view of the external report.
The MEN has seen a draft copy of a Serious Incident Review done by the Greater Manchester Mental Health NHS Foundation Trust following the death of Rowan Thompson, who died weeks before Charlie.
At Prestwich he had observations every 15 minutes because of concerns about self-harm.
The review, a copy of which was sent to Rowan Thompson’s father, said ‘there were shortfalls in how the observations were carried out’ on the day of his death. However it added that ‘there was also evidence of good practice when a random audit of CCTV footage was carried out.’
The review describes how Rowan, who was being treated at Prestwich’s Gardener Unit after being sectioned under the Mental Health Act, had undergone blood tests after experiencing weight loss.
The sample was processed the day before he died at a laboratory at Salford Royal Hospital and it indicated that he had ‘very low’ levels of potassium. But the lab was unable to reach anyone at Prestwich Hospital to alert them, despite trying several times.
The following day Rowan died. His cause of death of him is not yet known. The review found that ‘staff on The Gardener Unit did not follow Trust policy regarding observations’ and ‘the abnormal blood results were not communicated to the Unit due to a range of issues.’
A date is yet to be set for a full inquest into the death of the third youngster, Ania Sohail.
But at an inquest opening hearing in July last year it was revealed that Ania died after becoming drowsy during dinner, at the junction 17 unit for adolescents and young people at Prestwich, before saying she had taken a large amount of medication.
The inquest heard that it is not known how Ania, who had been at risk of self harm and had been on five minute observations, obtained the medication. A date is yet to be set for a full inquest.
Gill Green, Chief Nurse for Greater Manchester Mental Health NHS Foundation Trust said of the latest developments: “The Trust has been asked by NHS England and NHS Improvement to commission an independent report into the three tragic incidents; to be undertaken by an external organization to ensure complete neutrality wherever possible.This is in addition to conducting our own robust reviews into each of the incidents.
“We are cooperating fully with the inquiry process and will share the findings of our report with the families, our commissioner, NHS England, NHS Improvement, and the Coroner.”
Asked when the report would be complete and who would carry it out a spokesperson for the Trust said it was “too early in the process” to say.
In a statement NHS England said: “I can confirm that following discussion with the trust, NHS England and NHS Improvement recommended that the trust commission an independent report in order to ensure complete neutrality in that work. We will be supporting the trust to determine the terms of reference for that work to ensure it is robust and independent.”
The Manchester Evening News understands that an internal Trust investigation into Ania’s death is not yet concluded.
It is understood that once the local investigations by the Trust conclude then the intention is for the Trust to commission the external review to look into the learning from these deaths and an overview of the Trusts systems and processes to determine wider learning.
Rowan’s father, Marc, told the MEN this was ‘totally inadequate’.
“This is management politics and image control,” he said. “It is stalling a full investigation into the management and culture of the Trust.
“It is not even going to be an external investigation. It is a review – looking into the learning from these deaths – not the causes, not the underlying problems.
“In my view it is totally inadequate. It will not have the same scope that an investigation by NHS England would have, or the power.
“We will have to put our faith in NHS England, that they do ensure the terms of reference are robust.
“But the Trust commissioning the report puts control of the process in the hands of the people under investigation.”
Charlie’s mother, Samantha Millers, from Old Trafford, added: “Our aim is to get NHS England’s attention to do an investigation into the deaths.
“The fact that there have been three deaths in nine months is not acceptable.
“I know they are separate deaths but collectively we think the same issue arises – observation failings. I feel if NHS England get involved they can find out the facts.”
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