Anger after GMMH Trust says it has no plans to publish ‘independent’ review into to deaths of three young people

“We want to know what it says and the wider public has a right to know.”

Families have blasted a NHS Trust after it said it did not intend to publish an independent review into their loved ones deaths. Three young people died in nine months at the same mental health unit.

A Coroner was told last week that the review will be “ready” this month. Rowan Thompson, 18, died while a patient at the unit, based in the former Prestwich Hospital, Bury, in October 2020, followed by Charlie Millers, 17, in December that year, and Ania Sohail, 21, in June last year.

Earlier this year, Greater Manchester Mental Health NHS Foundation Trust (GMMH), which runs the hospital, commissioned an ‘external report’ into the deaths. On Tuesday last week a pre-inquest hearing into the death of Rowan – who used the pronoun ‘they’ – heard that the full report would be available for the coroner to read ‘on or around September 30’
Trust ordered to produce report after deaths of three patients at Prestwich Hospital

Asked by the Manchester Evening News if the review would be published a spokesperson for the Trust said the Trust “always act on the wishes of the family regarding publication of reports,” adding “and so in line with this we have no immediate plans to make the report public.”

But the parents of both Rowan Thompson and Charlie Mllers said they wanted the report publishing. Charlie’s mother, Sam, said: “We want it published. It needs to be put out there, otherwise there is no point in having it. We are hoping they (The Trust) will learn lessons. We want answers but it should also be published for the benefit of the wider public – and the parents of other young people who are being treated in that unit.”

Rowan Thompson (Image: MEN Media)
Charlie died five days after he was found unresponsive in his room at the Prestwich unit on December 2, 2020. His inquest should have been held started on February 28th 2022 but was delayed due to the Trust commissioning the review. It is now scheduled to take begin on January 30th 2023. Sam said: “It is disgusting how we have had our inquest delayed almost a year for a report that they have not even submitted on time. It was supposed to be ready in August.”

Last week sitting at Rochdale Coroners’ Court, senior coroner Joanne Kearsley ordered that a copy of the review – authored by consultant psychiatrist Dr Lisa Rippon – be sent to her by September 24. A full inquest into Rowan’s death is due to begin at the end of next month.

The hearing was also told that a blood test sample processed on October 2, 2020, showed Rowan was suffering from ‘severe hyperkalemia’ – a condition in which a person has too low a concentration of potassium in their blood. They died the following day.

Ms Kearsley said the inquest would look into Rowan’s treatment plan and what advice doctors gave to GMMH regarding emergency treatment. It will also look into the impact of the drug flucloxacillin, which Rowan was given just hours before their death.

At a previous hearing, a lawyer representing Rowan’s family revealed they had a number of concerns regarding Rowan’s treatment while a patient on the Gardener Unit at Prestwich Hospital. They claimed there were ‘systemic issues regarding observation of patients on the unit’, and that the campaign group Inquest had expressed concerns following a number of deaths, including Rowan’s.

The inquest into Rowan’s death will be heard by a jury and is due to begin on October 24. A second pre-inquest review into the death of Ania Sohail is due to take place on December 16th.

Rowan’s father, Marc, said: “The review is a desk top exercise. It is a review of the Trust’s processes and policies. The families have not been involved – so how can they say they are adhering to a family’s wish when we have not been involved. We want to know what it says and the wider public has a righ to know.”

Marc Thompson (L) and Sam Millers (R) outside the Prestwich Unit where their children both died. (Image: MEN Media)
Previoulsy Marc, told the M.E.N the review was ‘totally inadequate’. He said last year:”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.”

The review was commissioned by the Trust in March this year. NHS England and NHS Improvement as commissioners for the care of Charlie and Rowan and Manchester Clinical Commissioning Group. commissioners for the care of Ania, supported the request for the review.


The terms of reference for the review, drawn up by NHS England were to conduct “a desk top review” of the Trust’s Root Cause Analysis Serious Investigation reports for all three deaths “to ensure that they followed correct procedures, were thorough and complete, and recommendations made comprehensive “to both mirigate against further reoccurence and identify any further learning.

It was to focus on risk assessment; observations and monitoring of those observations; communication between professionals; and staffing levels. It was also to consider “and if appropriate” identify any new or emerging common themes or causal factors emerging from reviewing the three cases.

Gill Green, Chief Nurse at Greater Manchester Mental Health NHS Foundation Trust (GMMH), said: “We express our deepest sympathies to the families of, and all who cared for, Rowan, Charlie and Ania. We are fully cooperating with the inquest process. It would be inappropriate for us to comment further until the inquests have concluded.”

Full story here

Source: Manchester Evening News, 13th September 2022

Published by CHARM Greater Manchester

CHARM, the Community for Holistic, Accessible, Rights Based Mental Health was launched by The Organic Recovery Learning Community in September 2020.

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