CHARM Latest News

Communities for Holistic Accessible Rights based Mental Health

We are a campaign calling for changes in the way psychiatric services are provided in Greater Manchester.
We’ve teamed up with people with lived experience, workers, trade unions, family groups and citizens 
We are calling for a root and branch review and an action plan to transform mental health services in our communities.
Can you help? Contact us here

Next CHARM Supporters Meeting

Tuesday, 3rd May 2022 at 18.30

As usual the meeting will be held on Zoom. See link below:

CHARM Zoom Meeting

Join Zoom Meeting

Meeting ID: 863 0572 3349
Passcode: 116900

The agenda for the meeting is as follows.

Feedback on JGM Evans letter of support from CHARM and responses from CCG, CQC and Lucy Powell

Crisis in Manchester Services update

Co-design Collaboratives for “Living Well” update
On the 22nd April we were notified that “the senior leaders who sit ‘above’ the Collaboratives, which includes CCG and MCC commissioners, GMMH leads, and various VCSE CEOs, notably of MIND, MACC and 42nd St. held a meeting and decided that further work at their level is necessary (essentially to develop their vision and governance arrangements, and for them to further understand what the data and ethnographic research is telling them) so that they can support, assist and shape the work on which we are about to embark and have directed the Operational Managers to pause the Collaborative meetings in Central, North and South Manchester.”


Mental Health Action Group Research Launch: It’s My Medication, Thursday 5th May 11am-1pm for the launch of ‘It’s My Medication- Mental Health & Homelessness in Manchester’

Justice For Care/ CHARM Joint Meeting, Sunday 8th May 14.00 Zoom

Launch of Manchester Hearing Voices Network, Wednesday 25th May, 19.00 at The Yard, Work For Change, 47 Old Birley Street, Hulme, Manchester

Discussion topics

Equalities – Why no women’s only rehabilitation services provided by GMMH

Wider issues re. national picture on outsourcing to private sector and poor quality of services

GM Integrated Care Commissioning System -what do we know?


Coroners warned of mental health care failings in dozens of inquests

Observer investigation identifies 56 cases in which patients lost their lives after being unable to access the help that they needed.

Shortfalls in mental health services and staffing have been flagged as concerns in dozens of inquests since 2015, the Observer can reveal, with coroners issuing repeated warnings over patients facing long waiting lists or falling through gaps in service provision.

The Observer has identified 56 mental health-related deaths in England and Wales from the start of 2015 to the end of 2020 where coroners identified a lack of staffing or service provision as a “matter of concern”, meaning they believed “there is a risk that future deaths could occur unless action is taken”.

Coroners issue Reports to Prevent Future Deaths (PFD) when they believe action should be taken to prevent deaths occurring in future, and send them to relevant individuals or organisations, who are expected to respond. In one case, a woman referred to psychotherapy services had still not received any psychotherapy by the time she died 11 months later. In another, someone had endured a seven-month wait for a psychological assessment.Advertisementhttps://fccdde4c2292aba023508c38b58b4ba6.safeframe.googlesyndication.com/safeframe/1-0-38/html/container.html

Alison Cobb, senior policy and campaigns officer at the mental health charity Mind, said: “It’s shocking that so many should lose their lives because there isn’t enough capacity in mental health services to provide adequate care. These prevention of future deaths notices are meant to inform better ways of working, and it’s especially concerning that similar stories are repeating over and over again.”

Many of the cases are suicides. The causes of suicide are complex, and there is rarely a single event or factor behind them. PFD reports do not set out to identify why someone decided to take their own life, and rarely go so far as saying that a particular factor made death more likely by denying the victim the necessary support.

However, in the PFD report for a man who died in December 2019, the coroner wrote that moves to admit the victim as an informal patient at the hospital’s psychiatric unit floundered as “there were no beds available in Suffolk, or anywhere else in the country at the time”.

The coroner wrote: “Had a bed been available and had [he] been admitted as he and medical staff had wished on the evening of the 16 December 2019, his death would not have occurred.”

In another case, the PFD report for a 15-year-old boy who died in October 2018 warned of a lack of NHS services for autism and a “severe shortage of inpatient psychiatric beds for children and adolescents in the NHS”.

Dr Rosena Allin-Khan, Labour’s shadow minister for mental health, said: “The Conservatives have cut a quarter of mental health beds since 2010. This has put the NHS at breaking point, with devastating consequences for people’s lives.

A DHSC spokesperson said: “Every death by suicide is a tragedy and we are committed to ensuring everyone has access to the services when they need them.

“We are expanding and transforming mental health services in England, backed by £2.3bn a year by 2023-24, including £57m of investment in suicide prevention by 2023-24 to support local suicide-prevention plans and the establishment of suicide bereavement services in every area of the country.”

See full article here

Source: The Observer, September 2021


“Unless similar units cease to receive public money, such lethal outcomes will persist” says independent report into deaths of adults with learning disabilities at hospital

An independent report into the deaths of King, Nicholas Briant, 33, and 36-year-old Joanna Bailey, who all died at Cawston Park, said their relatives described “indifferent and harmful hospital practices”.

The report, published on Thursday, makes reference to “excessive use of restraint and seclusion by unqualified staff” and a “high tolerance of inactivity”.

“Unless this hospital and similar units cease to receive public money, such lethal outcomes will persist,” the report said.

How many people from Greater Manchester are living in Units like this?

The report into the deaths at Cawston Park has made 13 recommendations to a series of agencies including the Law Commission, suggesting a review of the law around private companies caring for adults with learning disabilities and autism.

“Given the clear public interest in ensuring the wellbeing and safety of patients, and the public sponsorship involved, the Law Commission may wish to consider whether corporate responsibility should be based on corporate conduct, in addition to that of individuals, for example,” the report said.

Flynn, who was commissioned by Norfolk Safeguarding Adults Board (NSAB) to write the report, said the report highlighted “failures of governance, commissioning, oversight, planning for individuals and professional practice”.

See full article here

Source: The Guardian, 9th September 2021

Transforming Mental Health Services: Whole Person, Whole Life-Whole System Approach Workshop

with Paul Baker and John Jenkins

Book your place on Eventbrite here

Over many years in developing community mental health services to replace the institutional system in the UK and a few other countries, the IMHCN recognised that we needed a more fundamental approach to ensure better mental health outcomes for service users and family members.

The social determinants were not adequately addressed so people’s whole life needs were not met. Therefore, in 2000 in NIMH(E) and IMHCN introduced the Whole Life-Whole System Approach. It is a strategic planning and implementation instrument to integrate and develop together the:

  • Social determinants of Health and Mental Health
  • Anthropological, Meaning and Culture
  • Philosophical: Challenging beliefs; Reflection and Dialogue
  • Whole Life, Recovery/Discovery Paradigm, Changing Thinking
  • Whole Systems: comprehensive community mental health services and development
  • Biological, clinical approach
  • Psychological therapies and psycho-educational tools
  • Education and Knowledge
  • Sharing and Learning from International best practice

This webinar will describe this approach and the results of its implementation in different places and organisations.

Who should attend?

Managers, professionals, service users, family members, Community Organisations

Autistic girl, 14, unlawfully detained in hospital, high court judge finds

The high court in London. Mr Justice MacDonald described the hospital environment into which the girl was placed as ‘brutal and abusive’.
In his judgment, MacDonald refused to grant a request from Manchester City Council for the local authority to remain anonymous. He criticised the council for failing to find her a suitable placement throughout the month she was unlawfully detained in hospital, accusing the council and unnamed NHS trust of having “comprehensively failed in this case”.

A 14-year-old autistic girl was unlawfully detained in hospital and restrained in front of scared young patients, a high court judge has found.

On one occasion last month the teenager managed to break into a treatment room where a dying infant was receiving palliative care. She was restrained there by three security guards, Mr Justice MacDonald said in a judgment in the family court that ordered Manchester city council (MCC) to find the girl a suitable community care placement instead of what he described as the “brutal and abusive” and “manifestly unsuitable” hospital environment.

Nurses witnessed the girl screaming “very loudly” and sounding “very scared” when repeatedly held down on her hospital bed so that she could not move her legs, arms or head, before being tranquillised. Other children on the ward were frightened to witness the frequent battles between the girl and security guards, the judge said.


The girl, who cannot be named for legal reasons, was brought to hospital on 15 February by her distressed father, who said the family could no longer care for her. The court heard that his other children had begun locking themselves in their bedrooms for safety and that he and his wife had resorted to locking the girl in the dining room to stop her escaping.

The judge noted that the teenager made “regular and determined” efforts to run away, sometimes using screwdrivers to try to unlock doors and windows, and running away from her family on walks. She was particularly vulnerable in the community, he said, because she lacked “any road sense or stranger danger and was previously found to have entered a stranger’s house and was found hiding in the bed”.

He described the teenager as having an autistic spectrum disorder and a learning disability. She demonstrated “complex and extreme behaviour” that could not be controlled even within a school environment involving six adults to one child supervision, he added.

Despite this, the council and NHS trust decided to have the girl be detained in hospital on a general paediatric ward “solely as a place of safety”, without applying for the necessary court order to do so, the judge found. She did not require any medical treatment, the judge said.

After her admission, the local authority employed a private company to provide two security guards and two carers to supervise the girl. The firm was engaged on a five-day rolling contract, leading to a high turnover of staff watching the girl night and day, resulting in “her waking up to unfamiliar adults and being scared by that change, further adversely impacting on her behaviour and wellbeing”.

She was unable to leave the locked ward, and the lock had been removed from her en suite bathroom door so that she had to keep it open even when using the toilet. She stayed there for a month.

Ordering her release from hospital into local authority care, the judge said: “It does not take expert evidence for the court to understand the adverse impact of the current regime, with its uncertainty, its concentration on physical contact and its location in a loud and unfamiliar environment, on a child who is autistic and learning disabled. What this must be like for [her] is hard to contemplate.”

In his judgment, MacDonald refused to grant a request from MCC for the local authority to remain anonymous. He criticised the council for failing to find her a suitable placement throughout the month she was unlawfully detained in hospital, accusing the council and unnamed NHS trust of having “comprehensively failed in this case”.

After the hearing, MCC identified a bespoke, short-term placement for the girl and said it continued to search for a residential educational placement for her.

A spokesperson for Manchester city council said: “We fully accept the judgment and its findings and together with the NHS trust are reviewing our role in this distressing case to make sure nothing like this can happen again.

“All our staff involved in the care of this young person have been spoken to and action taken where it has been needed. Although staff from each of the partner organisations involved in the young person’s care sought throughout to make decisions in the best interests of the young person, we acknowledge that the situation which arose, exacerbated by the national shortage of suitable accommodation for children with complex needs, was deeply unsatisfactory.”

Full story here

Source: The Guardian, 5th April 2022

Mental health team didn’t believe mum-of-one posed a ‘significant risk’ to herself days before train station death

Day two of the inquest in Stockport heard how doctors at the Bronte ward at Wythenshawe Hospital, where Kate was being treated after being sectioned under the Mental Health Act, felt her condition had improved enough for her to be discharged to the home based treatment team. This is despite earlier ‘manic behaviour’ on this ward and Kate going missing when granted unaccompanied leave.

Mental health practitioners did not believe a mum-of-one posed a ‘significant risk’ to herself in the days and weeks leading to her death, an inquest has heard. Kate Hedges, 35, passed away at Gatley train station in November 2020 having been released from hospital in October and referred to the home based treatment team.

Kate had been described as a ‘beautiful and bright person’ at an inquest into her death on November 27 2020 at South Manchester Coroners Court. She had long suffered with mental health issues after significant trauma when younger, including being bullied at school and raped when she was 19. She also cared for her young son who has autism. 

Her family yesterday raised further concerns that they were not involved in Kate’s care and were not regularly consulted by both the hospital ward and home based team she was discharged into. Day two of the inquest in Stockport heard how doctors at the Bronte ward at Wythenshawe Hospital, where Kate was being treated after being sectioned under the Mental Health Act, felt her condition had improved enough for her to be discharged to the home based treatment team. This is despite earlier ‘manic behaviour’ on this ward and Kate going missing when granted unaccompanied leave.

During her time at Wythenshawe Hospital Kate was diagnosed with bipolar disorder, which she didn’t accept at first, before her mental state gradually improved. The court heard yesterday from Dr Muhammad Imran, a consultant psychiatrist at Wythenshawe Hospital, that from her admission on September 9 to his last interaction with her on October 20, she had become calmer, but he did not believe she was ready to be discharged.

Despite this, on October 27, following a consultation with Mr Jon Lysons – a mental health practitioner with the home based treatment team at the hospital – and Dr Muhammad Iqbal – a registrar on the ward – it was determined that Kate’s condition had improved enough and home based treatment was appropriate for her. Mr Lysons said Kate was finding the ward environment ‘distressing’ but she was very calm when he spoke to her.

Mr Lyons said he “did not have any concerns she was not ready” for home based treatment and that it would be the best place for her. Dr Iqbal led the discussion with Kate around discharging her to the home based treatment team, agreeing her condition had ‘improved’ in the weeks leading to October 27.

“Kate was very much involved and engaged in the conversation,” he told the court. “She expressed herself and said she felt much better.” Dr Iqbal added she was no longer displaying any psychotic symptoms that had led to her sectioning and that the legal justifications for her detention were no longer warranted.

It was discussed with Kate about staying in the hospital voluntarily but she was keen to return home as the ward can be an ‘intense’ and ‘detrimental’ environment. Dr Iqbal said Kate was responding well to her medication and she wanted to be back at home with her young son.

“We concluded that discharging her with the home based treatment was the most appropriate step at that time with Kate involved with decision and agreeing to it,” Dr Iqbal added. Kate returned to her home in Burnage and would soon move to Gatley.

Andrew Barron, a mental health practitioner from Greater Manchester Mental Health’s home based treatment team, first started meeting with Kate at her home every other day on October 30. He said her mental state appeared ‘settled’.

“She was motivated to do things and was hopeful for the future,” he also said she had a good support network of friends and family in place. He added that they would not reach out to the family as par of the course as an adult with no immediate safeguarding concerns.

Kate continued to improve over their meetings, Mr Barron said, and despite moving homes was coping well. Matthew Baron, representing Kate’s family, raised concerns that Kate’s family were not involved in discussions with the home based team about their treatment. Kate had told Mr Barron she had a ‘strong support network’ and that because of this the home based treatment team ‘would not normally get involved’ with the family unless there were immediate safeguarding concerns.

After their last meeting on November 6, Jacqueline Cox, another mental health practitioner, became Kate’s named worker, meeting Kate for the first time on November 14. At this point Kate had been moved into ‘green’ on a traffic light system as her condition improved, having been on ‘amber’ when first discharged, meaning she was visited less frequently by a practitioner.

Ms Cox described Kate as very ‘pleasant and warm’ when they first met. Kate had been very positive about the move from Burnage to Gatley and her mental state was good.

Area coroner Christopher Morris told Ms Cox about evidence from Kate’s sister, Maya Hedges, told to the court yesterday (April 19) about how Kate became ‘withdrawn’ and ‘didn’t know who she was anymore’ after this move. Ms Cox did recall that Kate told her she was ‘bored’ and wanted to get back to work. She was also frustrated at not being able to drive and Ms Cox helped Kate come up with plans to validate these frustrations and overcome them.

“I didn’t feel there was any escalation of risk and I wanted to help her achieve her goals,” Ms Cox said. Kate did say she had begun feeling a bit low but was still planning for the future with her son and didn’t talk of harming herself which reassured Ms Cox.

At the next meeting Kate admitted her medication had made her feel like a ‘zombie’ at times but Ms Cox still felt there were no risks to her safety or wellbeing at that stage. Ms Cox’s last meeting with Kate happened on November 23.

“She reported an improvement with taking less medication and had spent time with her family and strong support network,” she said. “At that time I did not have any express concerns around Kate’s safety or wellbeing but I was still trying to support Kate as best I can with her trying to come to terms with her illness. There were no significant risks in that last appointment.”

Kate was set to be slowly discharged to the community mental health team from this point, and had been assigned a worker for this. However, Kate died four days later.

Full article here

Source: Manchester Evening News, 21st April, 2022

Schoolgirl, 13, ‘did not intend to end her own life’, coroner rules

Faith Hindle, from Salford, killed herself a day after telling an “overburned” mental health nurse that she feared she was unable to keep herself safe. She was pronounced dead at Royal Manchester Children’s Hospital after being found hanged at her family’s home in Cadishead on the evening of December 8, 2018.

At an inquest at Bolton Coroner’s Court today, a coroner ruled that Faith, a pupil at Irlam and Cadishead Sports College, died as a result of “misadventure”. The hearing was told that in the months prior to her death, Faith’s family, school and GP practice had tried to help her access mental health support after she began self-harming.

In August 2018, two referrals were made to Salford Children and Adolescent Mental Health Service (CAMHS) after Faith attempted suicide, the inquest heard. Tayaba Nicholson, a mental health practitioner at Salford CAMHS, picked up the referral and promised to see Faith on a “three to four week basis”.

Dawn Dunleavy, a mental health practitioner at the Salford Mental Health Liaison Team – based at Salford Royal Hospital – said she saw Faith on September 17 after she took an overdose at school. She said Faith told her she had had a row with a friend and had taken the overdose as “she thought it might help her forget”.

Ms Dunleavy said the teenager denied any suicidal thoughts but admitted having previously cut her arm while upset. She next spoke to Faith when she was brought to A&E by her father, Lee, after she punched a wall at school and bruised her hand.

Faith also appeared to have a ligature mark on her neck, Ms Dunleavy told the hearing. Salford CAMHS were informed and Faith was referred to the Junction 17 wing at Prestwich Hospital.

The inquest heard that during an appointment with Ms Nicholson on November 27 – after being discharged from Junction 17 – Faith rated her mood as “two out of ten” and revealed that she “still wanted to kill herself”. At the time, the risk to her was deemed to be “high” but the hearing was told it had then been reduced before her next appointment on December 7.

During that telephone consultation- the day before Faith’s death – she told Ms Nicholson that she was experiencing suicidal thoughts on a daily basis and felt unable to keep herself safe. However, the inquest heard that Ms Nicholson deemed Faith’s presentation on the phone to be “as before” and that any risks were managed.

Faith’s parents were not informed of what she had said during the appointment and Ms Nicholson told the inquest she had a “very heavy caseload” at the time.

The following day, Faith met up with a group of friends. When the friends left her shortly before 8pm, they said she seemed to be in a “good mood”. The inquest heard Faith then returned home before her mother found her hanged in a bedroom at 10.20pm.

Paramedics attended and Faith was taken to Royal Manchester Children’s Hospital where she was pronounced dead by medics. A pathologist gave Faith’s cause of death as “hanging”.

An inquest into Faith’s death was held at Bolton Coroner’s Court (Image: MEN Media)
Recording a conclusion of “misadventure”, coroner John Pollard ruled that Faith “did not intend to bring about her death”.

Full article here

Source: Manchester Evening News, 11th April 2o22

‘Special’ son, 22, died after ‘never getting over’ his counsellor using gravestone reference in therapy

A counsellor apologised to a client after using imagery of ‘a gravestone’ in a therapy session, a court heard today. Benjamin Davis then took his own life only a few months later, having ‘never got over that experience’, his father said.

During an inquest in Bolton today (April 13), private counsellor Avremi Rosenberg admitted that he should have used different wording in his session with Benjamin, who was 21 at the time. He also accepted that the language was ‘inappropriate’.

he youngster was also diagnosed with autism in 2021, assistant coroner Rachel Syed heard. After this diagnosis, Benjamin had five counselling sessions with Mr Rosenberg in spring last year.

And it was during these sessions in which Mr Rosenberg referenced a gravestone, Mr Davis said. He added: “I asked Mr Rosenberg about it and he confirmed he did [say it].

“My son is autistic and he cannot process things in the way other people do. If you mention a gravestone to me, it is okay, but if you mention it to autistic people they will focus on the picture of the gravestone.

“You have to be careful with language… they take things very literally. He told me that he started to think about death again after that. He never got over that experience. He was in a good place with autistic acceptance.”

When asked why used the imagery, Mr Rosenberg said he said ‘in the context that his autism diagnosis was… part of him but not all of him’. He added: “Benjamin approached me because he knew I was a counsellor with experience with working with people on the autism spectrum. In hindsight, this would have been better dealt with by the NHS. I did apologise to Benjamin for the way it came over.

“It was definitely not said in a blunt way. It was very much in the context that his autism diagnosis was very important and it was part of him but not all of him, and in that context what would be written on his gravestone. In the future whatever I can do to help you to come to terms about what has happened, I would properly arrange it. I express my sincerest, sincerest condolences.”

When asked by the coroner if his choice of words was ‘inappropriate’, Mr Rosenberg replied: “Definitely, yes.” Ms Syed said at the conclusion of the hearing that she would be writing a letter of concern to Mr Rosenberg’s organisation.

She also will be writing letters of concern to Benjamin’s GP surgery — Whittaker Lane Medical Centre — and Greater Manchester Mental Health Trust (GMMH). The coroner explained: “A formal letter of concern will be written to the GP, GMMH, and the private organisation, highlighting the need to ensure a more collaborative working approach between these organisations and sharing information such as diagnoses of autism.

Full article here

Source: Manchester Evening News, 14th April 2022

Anti-psychotic drugs contributed to death of man with mental health history, inquest hears

A man died after a build up of side effects from a drug he was taking to treat his paranoid schizophrenia led to his organs failing, an inquest heard.

John Warren had battled mental health problems since his early 20s. He was diagnosed with paranoid schizophrenia in 1988, a jury at Manchester coroners court heard.

He was moved to the Priory psychiatric hospital at Cheadle Royal hospital in 2000, where he had been ever since.

Tragically, though, side-effects from a drug – clozapine – caused internal problems and, after he was not able to have surgery at Wythenshawe Hospital, he died a few days later.

Concerns over John’s care leading up to his death at the Priory and Wythenshawe hospital have been raised by assistant coroner Ms Angharad Davies, which the jury will make conclusion of. His treatment with clozapine and its side effects as well as John not having the surgical procedure were also raised.

John used drug ‘of last resort’

The inquest heard John had been prescribed the drug clozapine for his paranoid schizophrenia, described as being a drug used in the ‘last resort’ when other medication doesn’t have the required effect.

He is said to have managed his mental health ‘reasonably well’ at the Priory, where he was monitored on a daily basis.

Dr Sheetal Rajashankar, a consultant psychiatrist at the Priory, described to the jury that Clozapine has a number of side effects, including causing constipation.

“It’s a very effective drug but does come with side effects,” Dr Rajashankar said.

John had a number of physical health problems in his time at the Priory, including testicular cancer and pneumonia, as well as known side effects from clozapine.

The jury was told that John was taken to A&E on Novermber 26, 2020, at Wythenshawe hospital after passing ‘dark coloured stools’. A doctor in A&E referred him for a gastroscopy to check for gastrointestinal bleeding on December 17 and told the Priory if he were to become ill again to take him straight to A&E.

He was taken to A&E again on December 2, but discharged soon after. On December 16, Dr Rajashakar took annual leave, to return on December 30.

In the meantime, John attended Wythenshawe hospital for the gastroscopy procedure on December 17, however, the doctor decided that he [John] did not understand the procedure enough, and therefore could not consent to it. The procedure did not take place and he returned to the Priory.

Dr Geeta Prasad, a consultant Gastroenterologist at Wythenshawe hospital, made this decision, telling the jury she felt John was “unable to consent to the procedure”. Dr Prasad also didn’t believe the surgery was an emergency but wrote an ‘urgent letter’ to the Priory to discuss if the procedure was still in his ‘best interest’ and could be done if he did not have the capability to consent himself.

A reply did not come from this letter, however.

On December 29, John attended A&E again after falling unwell. He displayed similar symptoms to previous A&E visits, such as dark and loose stools, with scans showing faecal impaction, which was having a severe effect on his respiratory system.

John was a long term smoker who suffered from COPD, with the pressure on his respiratory system causing his health to quickly deteriorate. At 11am on December 30 he was pronounced dead.

His cause of death was recorded as acute respiratory failure, COPD and, intestinal obstruction due to clozapine induced constipation.

The two day inquest is being held with a jury as John died while under Section 3 of the Mental Health Act. The inquest continues.

Full story here

Source: Manchester Evening News, 4th March 2022

Family will have to wait for answers over son’s death at GMMH mental health unit

Charlie Millers was one of three young people to die at Prestwich Hospital over a nine-month period. Greater Manchester Mental Health NHS Foundation Trust (GMMH), who run the site, have been ordered to commission an “external report” about all three deaths by NHS England. A pre-inquest review held at Rochdale Coroner’s Court today, March 8, heard that the inquest into Charlie’s death could be delayed by “several months” due to this report.

An inquest into the death of a teenager being treated at a mental health unit in Prestwich will be delayed “several months” after the NHS trust in charge was ordered to produce a report into the incident.

Charlie Millers, 17, died five days after he was found unresponsive in his room at Prestwich Hospital on December 2, 2020 – just weeks after 18-year-old Rowan Thompson died whilst being treated at the same hospital. A few months later, Ania Sohail, 21, also died at the hospital, making her the third young person to die after being treated at Prestwich Hospital in nine months.

Now, Greater Manchester Mental Health NHS Foundation Trust (GMMH), who run the site, have been ordered to commission an “external report” about all three deaths by NHS England. A pre-inquest review held at Rochdale Coroner’s Court today, March 8, heard that the inquest into Charlie’s death could be delayed by “several months” due to this report.

Assistant coroner Lisa Judge told the court: “The hearing was aborted as a result of NHS England’s indication they wanted to conduct an inquiry. I’m afraid I’m not in a position in regards to any identification for a prospected date for the report to be completed.”

The court heard a notification of Charlie’s death was sent to the CQC, NHS England, and the care commissioners at the time, but it has taken until now for the report to be ordered as NHS England made the decision to investigate the incidents after a letter from his mum Sam and her legal representatives requested an independent review. Paul Spencer, representing GMMH, explained he did not know how long the report would take, but anticipated it would be “a number of months” before it was completed.

At the hearing, several statements and medical records were requested from the healthcare providers involved in Charlie’s care before his death, whilst he was living with him mum in Old Trafford, with the coroner requesting those be submitted to the court and the family by April. The full inquiry into Charlie’s death should have started last week, February 28, in front of a jury.

Sam Millers with a picture of her son Charlie (Image: MEN Media)
Postponing the inquiry until further notice, Ms Judge stated she would be unable to hear the full inquiry between May and August due to personal commitments, but felt it was “highly unlikely” that NHS England would finish the report prior to her return. The report will cover three cases at Prestwich Hospital, believed to be the deaths of Rowan, Charlie, and Ania.

An inquest into Rowan’s death is scheduled to take place at Rochdale Coroner’s Court in June this year, but the hearing may need to be delayed to allow for the report to be completed if it is not finished by then. A watchdog previously said it was “very concerned” about the safety of people using the services at GMMH after a damning report by inspectors found there was not always enough nursing staff and that bank or agencies workers used at the site did not always have enough training.

Rebecca Titus-Cobb, a lawyer representing both Rowan and Charlie’s families at their respective inquests, had previously told a hearing into Rowan’s death that there were “systemic issues regarding observation of patients on the unit” – a concern shared by both families.

Speaking after the hearing, Charlie’s mum Sam Millers said: “I’m glad it’s been delayed because it gives us more time to gather the evidence and have more time to get everything together. If it had gone ahead I think it would have been half-hearted with statements missing.

“I’m ok with it being delayed because it’s for the right reasons. I wish it was all done and over with but if I’ve got to wait 15 years for justice for Charlie then I’ve got to wait.”

Full story here

Source: Manchester Evening News, 10th March 2022

Man discharged from MRI mental health unit died hours later after trying to take own life outside

Daniel Kirton may have had his ‘right to life’ breached, a pre-inquest review heard today.

A man who died after trying to take his own life inside hospital grounds just hours after being discharged from its mental health unit could have had his ‘right to life’ breached, an inquest heard.

Daniel Kirton, 35, visited the mental health team at Manchester Royal Infirmary on December 3, 2020, before he was discharged.

Tragically, though, after he left he tried to take his own life on hospital grounds, before ‘rolling’ onto nearby Upper Brook Street. He was hit by a taxi at around 11.35pm and pronounced dead in the hospital on December 4.

who was unemployed and of no fixed abode, passed away at Manchester Royal Infirmary in December 2020. On December 3, the 35-year-old visited the mental health team at the hospital.

He was then discharged. Mr Kirton attempted to take his own life on hospital grounds, before ‘rolling’ onto Upper Brook Street.

READ MORE: Police officers should have stopped high speed chase which ended in teen’s death, jury says

An inquest into Mr Kirton’s death was opened on December 23, 2020, at Manchester Coroners Court. A pre-inquest review was also held on November 18 last year.

A further pre-inquest review took place today (March 3), during which coroner Zak Golombeck submitted that an ‘Article 2’ inquest needed to take place into Daniel’s death.

“I’m satisfied there was an Article 2 (right to life) breach of operational duty,” Mr Golombeck said.

The scope of the inquest will look at concerns over whether Daniel should have been admitted to hospital after coming into A&E, his management by the hospital and the mental health trust on December 3 and 4. It will also look at concerns over how three security guards dealt with Daniel on the hospital grounds.

Sam Harmel, representing the family, agreed with Mr Golombeck, saying: “There is no doubt this was an individual who was vulnerable who’d attempted suicide two or three ways on the grounds in the space of two and a half hours after being in A&E.

“If there are situations starker than this (for Article 2) than I’m struggling to see one.”

Interested persons representing the hospital and the Greater Manchester Mental Health Trust have 14 days to put submissions to the coroner against it being an Article 2 inquest.

Statements are also being sought from two nurses who were with Daniel for a time outside the hospital buildings while still on the grounds.

Mr Golombeck does not believe a jury will be needed for the trial, however, this could change.

No official date has been set for the full inquest, but Mr Golombeck said it is likely to be after summer this year and will probably take multiple days.

Full story here

Source: Manchester Evening News, 3rd March 2022

Mental health service failings possibly contributed to dad killing his baby son, coroner says

A coroner has delivered a damning condemnation of the mental health treatment of a psychotic man in the months before he threw his 11-month-old son into a river and to his death.

The failures leading up to the horrific events which claimed the life of Zakari William Bennett-Eko on September 11, 2019, represented an ‘arguable breach’ of Article 2 of the Human Rights Act , which says government organisations have a fundamental legal duty to protect life, the Rochdale inquest was told.

Senior coroner for Manchester North, Joanne Kearsley, said there were ‘many failings and missed opportunities’ in the care of dad, Zak Bennett-Eko, who was later convicted for his son’s death of manslaughter by diminished responsibility and sentenced to a hospital order. He may never be released.

Ms Kearsley was bringing to a close a three-week long inquest into the death of baby Zakari, who died as a result of immersion in cold water after being thrown into the River Irwell at Radcliffe, just yards from where they lived.

She said: “As important as they [the failings] are, many cannot be said to have had any direct causal link to September 11. In fact, it must be remembered that, in terms of causing Zakari’s death, there is ultimately one person who caused his death.”

But she went on: “There is one factor which I find can be said to have contributed to the death, in that I am satisfied on the balance of probabilities there was a missed opportunity to ensure Zak had appropriate ongoing secondary [hospital] mental health input from January 2018 until September, 2019.”

Emma Blood says that Zakari’s father kept his schizophrenia diagnosis secret and she only found out six months after he killed their 11-month-old baby

Emma Blood said that Zakari’s father kept his schizophrenia diagnosis secret and she only found out six months after he killed their 11-month-old baby .

Referring to the treatment of the dad, who suffered from paranoid schizophrenia, ADHD and had mild learning difficulties, Ms Kearsley pointed to ‘the failure to have in place an integrated community learning disability service which provided psychiatric and mental health support and co-ordination’.

“On balance I find this was a missed opportunity which could have assisted in the prevention of a relapse, as there should have been an earlier intervention when he was not prescribed with his medication and when he was seeking help in May 2019 and later on.

“In addition, other professionals including GPs, social workers, the mental health liaison team [at North Manchester General Hospital ] and family members would have had contact with a service who knew him and when he was asking for help.

“The missed opportunity to prevent this relapse in my opinion possibly contributed to his actions on September 11.”

Delivering an ‘unlawful killing’ conclusion, Ms Kearsley said there was an ‘inadequate’ community learning disability service in place in Manchester. She said a care programme approach had been discontinued ‘when it should not have been and Zak did not have a worker in a care co-ordinator role which he should have had’.

She continued: “Between May and September 2019, necessary medication was not prescribed to the individual and it is more likely than not his mental health deteriorated during this time.

“On six occasions between August 31 and September 11, 2019, he sought help for his mental health and presented at his GP, A&E and the mental health liaison team.

“Had appropriate monitoring of the individual’s mental health care been in place, his presentation and medication could have been monitored and there would have been a care co-ordinator for other professionals and family members to liaise with.
“On the balance of probabilities, his non-compliance with necessary medication would have been identified at an earlier stage and it is possible that this could have averted the acute deterioration in his mental state.

“There is no evidence to suggest Zakari would have died if it had not been for the individual suffering a psychotic episode.”

Turning to Zak’s mum, Emma Blood, who since the tragedy has had a baby daughter, Ms Kearsley said: “I am sure I am not alone when I say I don’t think anyone can imagine the horror that you have had to endure and face.

“I hope this [inquest] helps your understanding as to why the events of September 11, 2019, happened. I know you have a daughter now and I hope that in the years to come you will remember Zakari with the love you clearly showed.

Footage shows chilling moment schizophrenic dad is arrested in pub – minutes after throwing baby son into a river…he killed the child thinking he was ‘the devil’men

Baby Zakari Bennett-Eko: The unthinkable killing that rocked a small town – and the haunting trial of a schizophrenic dad who ‘slipped through the net’men
Commenting on the coroner’s conclusion, Emma, said: “There should have been more monitoring in place and a care coordinator in place which I believe would have helped avoid the deterioration in Zak’s mental health that led to the death of my son.“

Kelly Darlington, solicitor for Emma, said “This is an extremely distressing case that no mother should ever have to experience.

“The inquest into the death of Baby Zakari highlighted a number of multi-agency failings in the care of his father who was experiencing a serious relapse of his psychosis at the time of the horrific events that led to his death.

“These missed opportunities may have avoided the serious deterioration in the father’s mental health that led to the unlawful killing of Baby Zakari.”

Eight organisations and baby Zak’s mum were legally represented at the inquest. The organisations were: Greater Manchester Mental Health Trust, Manchester City Council, Bury Borough Council, Manchester Clinical Commissioning Group, Manchester Foundation NHS Trust, Pennine Care NHS Foundation Trust, Mersey Care NHS Foundation Trust, Rock Health Centre and Greater Manchester Police.

Ms Kearsley has given legal representatives of all eight organisations 28 days to prepare submissions in advance of a ‘Regulation 28 Prevention of Future Deaths’ report.

The report will be sent to authorities which have the power to make the changes that are suggested. Organisations have to respond to these within 56 days showing how they have made changes according to the coroner’s recommendations, or how they intend to. All Prevention of Future Death reports and responses are sent to the Chief Coroner.

Full story here

Source: Manchester Evening News, 11th March 2002