Assistant Coroner Chris Murray recorded a conclusion of suicide of suicide following a three day inquest at Stockport Coroners’ Court, on Wednesday (May 5).
Mr Murray raised concerns about some aspects of Mr Thurm’s care and said he would be writing a ‘prevention of future deaths’ report.
During the inquest Mr Thurm’s parents, Alan and Sandra Thurm, criticised the treatment provided by mental health services.
“We felt let down by the NHS Greater Manchester Mental Health Trust,” they said
Stephen Thurm died four years after this sister Helena, 25, was killed by a dangerous driver in Altrincham. Architecture graduate Stephen, 32, was found hanged a in February 2020.
An inquest heard how Stephen had struggled with mental health problems in adolescence and this was ‘heightened’ after his sister was killed.
After the tragedy, the former Altrincham Grammar School and Nottingham University student, became isolated, attempted suicide and was sectioned on a number of occasions.
Giving evidence in court on the third day of an inquest at Stockport Coroners Court Mr Daniel Barber, a registered social worker at Trafford Local Authority, said Steven was isolating himself in his room.
He said his mood deteriorated when he was not busy and engaging in activities.
He said this was exacerbated by physical problems he had suffered including a hernia, injuries to the ligaments in his shoulder caused by a bike accident and a broken finger.
Mr Barber, who first met Stephen in March 2018, said he had expressed feeling “disconnected, lonely, envious and like he had no purpose.”
He said he had a very caring family who were very proactive with helping him with his health.
But Stephen had expressed he wanted to take more control and have more power over his treatment and complained of feeling ‘disempowered.’
Coroner Chris Murray said: “Stephen’s mood could change quite quickly.
“His parents were trapped in a cycle of despair. “
Mr Barber said Stephen told him he was having intrusive thoughts and was not wanting to wake up.
On June 27, 2019 the inquest heard Stephen had gone for a walk with Mr Barber and opened up to him about having suicidal thoughts two weeks previously.
Mr Barber had noted: “He opened up about feeling suicidal two weeks ago and said he was on the cusp of asking for hospital admission.
“Then his mood improved.”
Barrister, Mr Daniel Paul said the fact Stephen had said he was suicidal two weeks previously and claimed he had almost been asking for a hospital admission, despite always wanting to stay out of hospital, ‘set alarm bells ringing.’
He said to Mr Barber “It tells you a lot.” He posed a question as to whether risk assessment, showing Stephen to not be at high risk of suicide, should have been reviewed.
He pointed out that Stephen had been taken off the ‘Red Zone’ which meant he received up to three ‘contacts’ from the mental health team per week, ten days before the anniversary of Helena’s death.
Mr Paul said one of the problems Stephen also had was that while he expressed wanting to have psychotherapy – in order to have it, he had to demonstrate goals that he wanted to achieve and that he was motivated.
But to demonstrate he has this – he had to have psychology.
He said: “It’s a catch 22 situation and he was a bit stuck.”
Mr Barber said it was a worrying time for Stephen’s parents as he was going on a vandalism spree, smashing and ripping up photographs.
He said they could not keep up with his behaviour but did not want him to leave the family home for fear he would take his own life.
Answering questions, Mr Barber told Greater Manchester Mental Health representative, Sara Lyle, that Stephen was angry about being monitored by his parents and hence this was why he ripped up the family pictures.
Mr Barber told the court “We were all doing everything we could.
“There was a consistent attempt to do the right thing by Stephen.
Coroner Mr Murray posed questions to registered mental health nurse Candice French, service manager for the mental health trust, Trafford, as to whether care co-ordinators like Mr Barber were being given adequate time to write notes up contemporaneously if they were “bouncing from appointment to appointment.”
He asked if it was incumbent the care coordinator made it known if they were struggling to get things done in time. She said : “Yes, it is.”
Stephen was last seen by a psychiatrist in August 2019 and by a psychologist on a one-to-one basis in July 2018.
The family made a statement as follows:
“We support the conclusions of the South Manchester Coroner, who today outlined inconsistencies and failings in the care provided by the Trust, and by the Trust’s own internal enquiry, as to what went wrong which he described as ‘unsatisfactory’.
“We were saddened and disappointed that we had to engage a solicitor and barrister to forensically examine patient records to uncover the truth.
“The Trust’s internal enquiry was like an exercise in students marking their own homework, in that it failed to identify abundantly clear failings in its service delivery, its record keeping, and its employees.”
Mr and Mrs Thurm say they ‘repeatedly warned’ the Trust about their son’s deterioration and the urgent need for effective treatment but claim “our views were often ignored”.
They added: “We were recently bereaved parents, ourselves suffering from severe post-traumatic stress disorder owing to the violent death of our daughter, yet the Trust offered us little support and often side-lined us from decisions about our son’s care.”
They added: “The Coroner concluded today there is a wider issue to address in terms of the use of information gathered from the family and how that is reflected in the care plan. So, he will address the wider care arrangement in respect of mental health patients in a prevention of future death report.
“The Coroner’s conclusions are very welcome, and the full story has now been revealed.
“Nothing will bring back our beloved son, Stephen, but we hope that changes resulting from the Coroner’s findings might help future patients.”
Following a three day inquest at Stockport coroners’ court, Mr Murray recorded a conclusion of suicide.
He said: “Stephen had demonstrated over a long period of time a propensity to carry out self-harm. I am satisfied he had the intention to take his own life.”
Mr Murray raised concerns about some aspects of Mr Thurm’s care and said he would be writing a ‘prevention of future deaths’ report.
The concerns included ‘inconsistencies’ in moving Mr Thurm in and out of the ‘red zone’ – a term used to describe increasing a patient’s contact with the care team in response to a deterioration in their mental health, a lack of time for care coordinators to complete notes, a lack of support Mr Thurm’s parents and concerns about how information provided by the family was used in care plans.
Mr Murray said: “There does not appear to be support for families in cases such as this.”
Gill Green, director of nursing and governance at Greater Manchester Mental Health NHS Foundation Trust (GMMH) said: “We offer our deepest condolences to Stephen’s family, friends and all those who cared for him at this sad time.
“Our Trust is committed to continuous learning and improvement. Since the incident, we carried out an extensive internal review, which led to recommendations and a comprehensive action plan to help prevent similar incidents in the future.
“The action plan focused on training and supporting staff to follow all Trust policies and procedures around referrals to other services, and documentation. All actions have now been completed.
“We fully accept the findings of the Coroner, and will work rapidly to prioritise all further actions in their report. We recognise that we need to work more closely with the family and friends of our patients. We have a dedicated Service User and Carer Lead for Trafford, who works closely with our Trust-wide Carer Lead to improve staff communication with carers. They recently completed a rigorous audit of carer engagement in Trafford and a detailed action plan has been developed to ensure that all staff in Trafford recognise the important role family and friends play and incorporate their concerns into care planning wherever possible.
“We recognise this comes too late for Stephen, and our thoughts remain with everyone who was affected by this tragedy.”
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Source: Manchester Evening News, 6th May 2021
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