Sanm was discovered in a critical condition shortly later on Bank Farm Lane, about a mile-and-a-half from the hospital. Ambulance crews arrived quickly and started CPR and he was taken to the Royal Oldham Hospital but died three days later, on May 20.
Senior coroner for Manchester North Joanne Kearsley says Pennine Care NHS Foundation Trust, which runs Birch Hill Hospital, had already accepted a series of failures in the lead up to Sam’s death.
There was an absence of a risk management plan, and instead of just one member staff escorting him on a walk out of the hospital there should’ve been two.
There was a failure to liaise with his mother, Helen McHale, despite concerns raised by her at the risk to his safety following the death in the previous January of his younger brother Matthew.
When Sam left the facility, the carer should’ve had either a phone or radio to maintain contact with the hospital in case of an abscondment.
Although earlier complaints in 2018 by Helen over the care Sam was receiving were investigated and recommendations for improvements were made, they were not put into effect, Ms Kearsely was told by Clare Parker, the trust’s executive director of quality, nursing and healthcare professionals and deputy chief executive.
Ms Parker opened her evidence by saying: “I want to apologise to Sam’s family for the failings we have found in the investigation by Pennine Care. We have accepted six areas that at the time where there were failures and as a result of Sam’s case we’ve made amendments to our policies.”
Ms Parker said the quality of the nursing reports about Sam’s care – a key component informing how his nursing needs would be met – were ‘not of the standard the trust expected’.
Helen complained about a lack of communication between herself and the team caring for staff, and although it was recommended this would improve, it was not acted upon.
She also objected to the withdrawal of a ‘named nurse’ – a designated nurse who the family could liaise with. A named nurse is now part of the provision, Ms Parker said.
Helen earlier told the inquest Sam had been seriously injured in 2016 when he threw himself in front of a train and, as a result, had been detained in a psychiatric intensive care unit before being transferred to Prospect Place. He was diagnosed with paranoid schizophrenia in 2017.
She said she believed medical staff were consistently ‘under-estimating the risk’ to her son.
“I was worried about how distressed he was, but I was also worried about him going out and the safety of the public,” she said.
“We agreed to weekly calls from the medical team, but they weren’t calling me. He didn’t take a shower in 2019, and his carers weren’t communicating with me. It was like talking to someone who doesn’t want to listen.”
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Source: Manchester Evening News, 26th October 2021