A senior leader admits the issues when Rowan Thompson died were likely not a ‘one-off’
Bosses cannot check workers on a Prestwich mental health unit are carrying out observations using CCTV, despite five staff failing to do so correctly the day a teenager died, an inquest has heard. Rowan Thompson died aged 18 on October 3, 2020.
The teenager, who identified as non-binary and used the pronoun ‘them’, was an inpatient on the Gardener Unit, run by Greater Manchester Mental Health NHS Foundation Trust (GMMH), on the site commonly known as Prestwich Hospital. Rowan’s inquest previously heard they were supposed to be observed every 15 minutes, but staff did not check on them for 90 minutes before they were found having a seizure.
At Rochdale Coroners’ Court this morning (Thursday, October 27), the inquest heard that five members of staff working on-site that day had either wrongly signed records of observation or failed to carry out the duty. Rachel Green, head of operations for children and adolescent mental health services (CAMHS) for GMMH at the time, told jurors she was working in an adjacent building to the Gardener Unit on the day of Rowan’s death.
She told the court that no staffing issues had been brought to her attention before the tragedy unfolded, and that she had not visited the Gardener Unit herself that day until emergency services were in attendance. It was the following day that Ms Green discovered staff had not carried out the checks as they had claimed.
The court heard Ms Green spoke to ward manager Rachel Campbell, who had spoken directly to the staff working the day Rowan had died, including one who admitted ‘she had not completed some of the observations that she had signed for’. Asked by coroner Joanne Kearsley if this was a concern, Ms Green replied: “Absolutely, yes.”
She added: “I was surprised to have heard that.” The inquest heard that wrongly signing the records would involve the member of staff signing the document, while also indicating if the patient was asleep or awake, even though they did not check on them. Ms Green said she informed Greater Manchester Police about the revelation, and officers requested CCTV footage which showed staff had not carried out the required checks for an hour and a half.
Asked if she considered it was likely five members of staff would have failed to carry out checks or falsify records as a ‘one-off’ on the day Rowan died, Ms Green said: “It seemed unlikely that it would all just be a one-off on that day.” The inquest heard that following the revelation and Rowan’s death, senior staff reminded support workers and nurses about the need for regular observations on the Gardener Unit, which was described as a ‘medium-security’ site.
Ms Green said a number of changes were made and senior bosses explored how observations could become more ‘efficient’ to help staff. But the changes did not include using CCTV – which exposed the lack of checks on the day of Rowan’s death – to ensure staff were carrying out the observations as required.
The court heard that the CCTV would only have shown staff in the corridor and not inside patients’ rooms, so there would not be an issue with confidentiality. However, Ms Green explained that staff had raised concerns about the use of CCTV to check they were carrying out their duties.
She said: “My understanding is that we can check the CCTV to check the details of a serious incident or allegation, but we are not supposed to use the CCTV to retrospectively check if staff are doing their jobs. It’s my recollection that there was an issue raised internally in the trust by our staff side.”
Jurors were also told that staffing numbers on the day were ‘sufficient’ in Ms Green’s opinion, with the ward not at capacity on the day. She admitted that falsifying observation records could amount to a disciplinary offence.
Rowan’s inquest, which began on Monday, previously heard that they were suffering from ‘severe hypokalemia’ – a condition in which a person has too low a concentration of potassium in their blood. Yet blood test results had not been communicated to those caring for Rowan on the Gardener Unit.
The jury heard that at the time of their death, Rowan – who had been diagnosed with autism – was awaiting trial in connection with their mother’s death. They were transferred to North Manchester General Hospital after suffering a seizure on October 3, 2020, but died on the same day.
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Source: Manchester Evening News, 27th October 2022