Mental Health Trust Watch

In this section we feature articles about the Mental Health Trusts operating in Greater Manchester. The two Trusts are the Greater Manchester Mental Health Foundation Trust and Pennine Care NHS Foundation Trust.

Our intention is to be able to identify issues and concerns across the services and we do this through monitoring media coverage of mental health services in our City Region.

As you will read below, there is growing evidence of systemic problems that have led to tragic outcomes. Between April and July alone there were 12 press reports of Inquests and Court cases involving GMMHT and Pennine Trusts.

Wee also record positive developments and initiatives.

If you have any information that you think we should know about and that we can share here please let us know.

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March 2022

Mother’s agony after suicidal daughter escapes from GMMH hospital despite being sectioned

A worried mother says her suicidal daughter escaped from a mental health hospital on numerous occasions. The woman says her 21-year-old daughter, whose names are being withheld to protect their identity, was sectioned under the Mental Health Act and admitted to Griffin Ward at Prestwich Hospital ten months ago.

The mother, who lives in Collyhurst, says her daughter’s mental health suffered terribly after her (the mother’s) father died four years ago, and then further declined when she was attacked by two girls in Piccadilly Gardens in Manchester last June.

She says her daughter was sectioned immediately after a member of public alerted police after seeing her stood on a bridge.

After attempting to take her own life, she spent a few days at Salford Royal and Park House before being transferred to the Griffin Ward at Prestwich Hospital. But she says her daughter has been able to escape from the hospital on several occasions and has further attempted to take her life each time.

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.

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.

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.

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.

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.

February 2022

New £3m model of mental health support agreed in Salford

A new citywide mental health service has been approved, anticipated to support an additional 5,000 people per year in Salford.

‘Living Well Salford’, jointly funded by NHS Salford Clinical Commissioning Group (CCG), Greater Manchester Mental Health Foundation Trust (GMMH) and Salford Primary Care Networks, is the name given to the new local system designed to meet the needs of adults with mental health problems that require more support than primary care can offer, but don’t meet the criteria for secondary care mental health services.

January 2022

Sam Millers and Marc Thompson want answers after both their teenagers were admitted to Prestwich Hospital and didn’t come back out alive

The parents of two children who died in hospital due to “observation failings” are demanding an independent investigation.

Sam Millers and Marc Thompson are parents from two different parts of the county who both lost their children after they received treatment at Prestwich Hospital.

Sam, from Old Trafford, lost her trans son Charlie, 17, in December 2020 after “observation failings” led to his suicide.

Meanwhile the death of Marc’s son, Rowan, 18, who identified as non-binary, two months later still remains a mystery.

Their children make up two of three young people who have died while being admitted at Prestwich Hospital over the course of nine months, and are now demanding answers.

December 2021

Union fears ‘dangerous’ low staffing levels at Greater Manchester Mental Health Trust are harming patients

As reported in the Manchester Evening News last week a watchdog is “very concerned” about the safety of people using the services of Greater Manchester Mental Health NHS Trust.

A damning report said inspectors found there were not always enough nurses and that permanent staff did not feel safe if bank or agency workers were used as they didn’t have the relevant training.

It follows an unannounced inspection in September by the Care Quality Commission “due to on-going concerns about the safety of services”.

Now UNISON says it is concerned about “dangerous” staffing levels across the Trust’s sites in Prestwich, Trafford, Manchester, Wigan, and Bolton.
A Unison spokesperson said: “Our members have reported across the Trust that staffing levels are at dangerous levels and that this is impacting both upon patient care and staff well-being.

“Some of our members within the Early Intervention Service have recently voted for strike action over Trust re-organisation plans which would leave their service even more stretched.”

Unison North West regional organiser, Lyndsey Marchant, added: “Staffing levels are causing problems throughout the Trust. Recent reports about Prestwich Hospital were incredibly worrying, but UNISON is also concerned about issues within our community mental health services.

“Community mental health services do vital preventative work, which can often avoid young people from people admitted to facilities like Prestwich Hospital.

November 2021

Cheadle Royal Psychiatric hospital ordered to improve after failing to provide ‘caring environment’ for patients

Cheadle Royal psychiatric hospital has been ordered to improve after a watchdog found it was failing to provide ‘a caring environment’ that respected patients’ dignity and helped them recover.

Cheadle Royal Hospital, in Heald Green, has in-patient wards for adults and children as well as specialist eating disorder services.

It was previously rated ‘good’ overall by the Care Quality Commission (CQC) at its last full inspection in 2017.

The service has now been downgraded to ‘requires improvement’ after officials identified a ‘number of concerns’ at a visit earlier this year.

This is despite the watchdog noting that ‘staff treated patients with compassion and kindness’ and ‘developed holistic, recovery-oriented care plans’.

The Priory Group, which runs the hospital, says it is ‘working hard to make the improvements identified’ by the CQC.

During the visit, safety was found to be ‘inadequate’ in the acute adult wards and psychiatric intensive care units, as well as on the child and adolescent mental health wards.

A newly published report notes that ‘not all wards were safe, clean, well equipped, well furnished, well maintained and fit for purpose’.

Man charged with attempted murder after patient stabbed at mental health unit

A man has been charged with attempted murder after a patient was stabbed in the mental health unit of a hospital.

Police rushed to reports of a stabbing on October 27 at Park House, which contains adult inpatient mental health wards on the North Manchester General Hospital site.

A man in his 30s suffered serious injuries and had to be treated at the scene before paramedics could rush him to hospital for further aid.

An ambulance, air ambulance and a paramedic in a response vehicle all attended the scene.

A man, also in his 30s, has now been charged with attempted murder, officers have confirmed.

The incident is under both a criminal investigation, according to the force and the trust which runs the unit.

A spokesperson for Greater Manchester Police has said: “Police were called shortly after midday (Wednesday 27 October) to a report of a stabbing at Park House, Manchester.

“A man in his 30s suffered serious injuries but is now in a stable condition.

“A second man in his 30s has been charged with attempted murder.

“This was believed to be a contained incident and GMP are working with staff at North Manchester General Hospital to investigate the circumstances.”

October 2021

September 2021

‘Inadequate’ care home that failed to protect residents from potential harm or abuse placed in special measures

A care home that was failing to protect its residents from potential harm or abuse has been placed in special measures.

Smithy Bridge Court, in Littleborough, provides care for up to 51 people with complex care and mental health needs, including dementia.

But it has been rated as ‘inadequate’ by health watchdog the Care Quality Commission (CQC) following an inspection of the new-build facility in Barke Street.

READ MORE: Firm that provides at-home care for people with a range of health conditions failed to ensure staff were competent, watchdog says

This is the lowest grading a care home can receive and if ‘significant improvements’ are not made within six months it could potentially be closed down.

The inspection was prompted in part due to concerns raised over staffing levels, management of medicines and safeguarding.

Source: Manchester Evening News, 23rd September 2021

Legendary dance venue hosting huge mental health awareness event for pupils

The events programme has been designed by young people and was delivered in partnership with Manchester-based mental health charity 42nd Street.

Depot Mayfield played host (Thursday September 23) to 215 Greater Manchester schools and a series of live performances, workshops and lessons to explore the wellbeing and mental health challenges faced by young people – as well as the support available to them.

Source: Manchester Evening News, 23rd September 2021

Heartbroken mum learned of son’s death on Facebook

Mental health staff believed Kieron, who grew up in Withington, was regularly using drugs.

However, the court heard how Kieron denied any claims and was often “aggressive or agitated” when on the ward.

He was discharged in 2019 and offered a place with the housing association one year before his death.

Speaking at the inquest, Ms Hamlin, who had not seen her son in two years, said she didn’t find out about his passing until she read it in a Facebook post in September 2020.

During a toxicology report, pathologist Dr Justin Nkonge said Kieron’s lungs were found to be four times heavier than they should have been.

Blood tests showed there to be cocaine and heroin in his system when he died.

Kathyrn Dykes, clinical Psychologist for the Greater Manchester Mental Health NHS Foundation Trust, said a number of areas of expectation within the trust were not met during Kieron’s treatment.

She said this was because of the pandemic and face-to-face meetings not being possible.

Speaking at the inquest, she said: “Kieron would leave Hollybank very early in the morning and return at night, making it hard for mental health nurses to contact him.

“Notes had not been updated on the system due to workloads at the time.”

Ms Dykes said although Kieron had been placed in the “red zone”, meaning patients are in crisis, he should have been getting three visits a week.

Source: Manchester Evening News, 22nd September 2021

Call for ‘urgent review’ at Prestwich Hospital following death of teenager accused of murdering mother, coroner told

A campaign group has called for an ‘urgent review’ of Greater Manchester’s mental health trust following the death of a teenager at Prestwich Hospital, a coroner has heard.

Rowan Thompson, who used the pronoun ‘they’, was found dead at the Gardener Unit at the mental health hospital on October 3 last year.

Rebecca Titus-Cobb, a lawyer representing Rowan’s family, told the inquest the family had a number of concerns regarding Rowan’s treatment while on the unit.

She said there were ‘systemic issues regarding observation of patients on the unit’, and that the campaign group Inquest had contacted the Care Quality Commission to express concerns following a number of deaths, including Rowan’s.

She added: “The family understand that Rowan’s death was one of four recent deaths across Greater Manchester Mental Health Trust units, Junction 17 and the Gardener Unit where Rowan passed away.

“Clearly there are concerns about the general operation of the units. Inquest have requested that the Care Quality Commission undertake an urgent review and or inspection of the trust.

“In particular, the letter raised concerns that similar criticisms of Junction 17 were made at the previous inspection in February 2016 regarding incomplete observation records and missing entries.

“There are concerns that the issues in Rowan’s case may be part of wider, broader concerns that have arisen not only in Rowan’s case, but other cases.”

At the time of their death, Rowan was supposed to be under 15-minute observations, the court heard.

Ms Kearsley said the inquest would look into the observations practices on the day Rowan died.

Ms Kearsley ruled that scope of the inquest would include the care and treatment Rowan received at the hospital, as well as the observations by staff at the hospital on the day of their death.

An inquest had been scheduled for December, but is now likely to take place next year before a jury.

Source: Manchester Evening News, 23rd September 2021

Mental health patients leaving hospital in first lockdown felt lonely and isolated

Mental health patients who were discharged from or admitted to acute mental health services during the first Covid-19 lockdown experienced loneliness and social isolation, according to a new study.

Published in the journal British Journal of Psychiatry, the 34 patients, carers and clinical staff were interviewed by a team of researchers from The University of Manchester.

The study was funded by the National Institute for Health Research Greater Manchester Patient Safety Translational Research Centre (NIHR GMPSTRC).

NIHR GMPSTRC is a partnership between The University of Manchester and Salford Royal NHS Foundation Trust.

Mental health service users also reported ‘working harder’ to avoid admission due to fears around environmental safety as a result of COVID-19.

Even before the pandemic, there are lots of safety concerns associated with recent discharge from inpatient mental health services, for example suicide and self-harm,“ said lead author Dr Natasha Tyler, researcher at the GM PSTRC and The University of Manchester.

Dr Tyler added: ‘Our patients and carers felt that because of the national need to free-up hospital beds, the quality of discharge and admission planning was compromised at times.

“That meant discharging patients from hospitals who were not ready to cope in the community or not admitting patients who needed in-patient care.

Source: University of Manchester, 16th September 2021

Local businesses raise £60K for new community mental health initiative

A football-themed fundraising initiative, organised by Foundation 92 and Redstone Accountancy, has exceeded all expectations by raising £60,000 in donations from the Greater Manchester business community, to fund a new community mental health initiative.

A football-themed fundraising initiative, organised by Foundation 92 and Redstone Accountancy, has exceeded all expectations by raising £60,000 in donations from the Greater Manchester business community, to fund a new community mental health initiative.

Source: About Manchester, 16th September 2021

‘No mental health bed’: why children end up on acute medicine wards

Over the last five years there has been a gradual increase in the number of children admitted on to our acute paediatric unit who don’t need the kind of medical treatment we offer.

Consistently this summer, 20% of our beds have been occupied by children who need either a specialist mental health bed or a specialist residential placement in the community.

Not long ago we had a looked-after child of primary school age with serious behavioural issues who ended up stuck on our ward for several weeks because the local council couldn’t find them an appropriate placement in Greater Manchester. It was heartbreaking because they ended up 100 miles away, far from anyone they knew.

Many of these patients are not getting the care they need because neither I, my colleagues or the nursing staff are trained to provide the level of psychiatric care they require. We are trained to deal with medical problems. The mental healthcare teams don’t have the capacity to provide the level of daily input that these children need.

Source: The Guardian, 13th September 2021

Patient endured an 18-hour hour delay following a mental health call-out

Paramedics for North West Ambulance Service (NWAS) have told the Manchester Evening News that one patient endured an 18-hour hour delay following a mental health “Category 3” call-out.

90 pc of ‘Category 3’ calls should be responded two within two hours.

It comes amid reports of queues of ’14 ambulances’ outside Stepping Hill Hospital in Stockport.

Source: Manchester Evening News, 10th 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

“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?

Source: The Guardian, 9th September 2021

August 2021

July 2021

Three young people have died at Prestwich mental health hospital in the last nine months

Three young people have died in a nine month period at Prestwich Hospital. Rowan Thompson, 18, died at the mental health hospital in Bury, in October, followed by Charlie Millers, 17, in December, and Ania Sohail, 21, in June.

The series of deaths has led campaigners to call on the Care Quality Commission to ‘urgently inspect the service’. In response, the Care Quality Commission told the Manchester Evening News they were reviewing ‘the information available to us and considering what actions’ to take. Paul Elliot, Deputy Chief Inspector for hospitals and lead for mental health said there were ‘areas for improvement’, adding: “We have made it clear that the trust needs to focus further on safety.

“In acute wards for working age adults and psychiatric intensive care units, staff were not following the trust’s policy in relation to rapid tranquilisation and in child and adolescent mental health wards, checks to ensure that equipment was safe to use had not always been carried out.”

Jodie Anderson, caseworker at the charity INQUEST, which is supporting the families of Charlie and Rowan, said they were ‘deeply concerned’.

“We await the inquests into these premature deaths, which must ensure the utmost scrutiny. However, we cannot wait for action on this hospital. In light of these three very recent deaths of young people in concerning circumstances, we call on the regulators the Care Quality Commission, to urgently inspect this service and ensure other young people in mental health crisis are kept safe.”

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Source: Manchester Evening News, 26th July 2021

Pennine Mental Health Trust failed young musician due to gap in provision

Self-taught drummer James Theophine was reported to the police in April 2019 and his mum Melanie Theophine said that the allegations ‘rocked his world’. James became dependent on alcohol and died from multi-organ failure in October 2020, aged 20. 

The court heard that after his 19th birthday, James had struggled to access mental health services after getting too old for the children’s mental health team. He was considered ‘too complex’ for the adults’ community mental health team and was referred to an organisation called Lanc UK, which was commissioned to run some mental health services.

Lanc UK director Dr Neil Rutherford told court that his organisation had already considered that James was too complex for the organisation to help him one month earlier – an issue his mum had previously highlighted.

Ms Fletcher from Pennine Trust said she had not been made aware of that, and would have found an alternative solution for James had it known.

Asked whether she believed there had been a gap in provision for James, Ms Fletcher said: “Yes.”

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Source: Manchester Evening News, 24th July 2021

High volumes of staff absences at GMMHT due to Covid-19 and poor communication between teams delayed help for Trauma Survivor who subsequently died

Salford Royal Hospital

Attempts to reach Catherine and start work to help her reduce her drug intake were delayed as liaison staff believed she had been discharged, while home treatment staff believed she was still in hospital.

In addition, high volumes of staff absences due to Covid-19 gave way to long waiting lists for appointments also delayed Catherine being able to get help, said Michael Hartley, who led the report by GMMH’s governance body.

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Source: Manchester Evening News, 16th July 2021

GMMHT receives 30,000 calls to 24/7 Helpline since March 2020

At the start of the pandemic Greater Manchester Mental Health NHS Foundation Trust (GMMH) set up a 24/7, all-ages helpline within a week, staffed by experienced mental health practitioners from a range of services, many of whom were shielding themselves but supported to work from home.

In their first ten days, over 1,500 calls were received, and during the height of the pandemic the call handlers received almost 550 calls per day.

Since 20 March 2020, they have handled almost 30,000 calls and since its expansion in May, have supported the Greater Manchester Clinical Assessment Service (CAS) and NHS 111 service by streaming their calls and supporting the caller to a solution which helps relieve pressure on other services, including ambulance call outs and attendances at A&E.

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Source: Rochdale News, 15th July 2021

Pennine Care sign staff health and wellbeing pledge

Pennine Care NHS Foundation Trust has become the latest NHS provider to sign a pledge supporting the principles of the Nursing Times Covid-19: Are You OK? campaign.

The trust signed up to support the campaign, after its Clare Parker, its executive director of nursing, responded to a call made by Nursing Times to NHS providers across the UK.

Pennine Care, which employs around 4,000 staff, provides mental health and learning disability services to people across Greater Manchester.

It runs a range of mental health and learning disability services for children and adults from sites in Bury, Oldham and Rochdale, Tameside and Glossop, and Stockport.

The trust highlighted that it had already taken a range of steps to protect staff mental health and wellbeing.

These include a dedicated staff wellbeing service offering support, counselling or therapy. Staff can self-refer or a referral can be made by a line manager.

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Source: Nursing Times, July 2021

Young man, 22, began struggle with insomnia on holiday and was dead within months, inquest hears

David Marsden’s family slammed mental health care workers for his ‘dehumanising’ treatment on a ward at a hospital he once worked. Desperate mum Fiona tried to help her son as he was seen numerous times by his GP, A&E at Stepping Hill Hospital, as an outpatient with a psychiatrist and by the community mental health team.

Fiona slammed Norbury Ward, run by Pennine Care NHS Foundation Trust, during her testimony in court, saying through tears: “The ward environment was not what I or David expected. It added to his lack of self-worth.

“He was in hospital to be cared for, treated to get better. It was a place where he was secure and safe from harming himself. But there were occasions when I witnessed him being referred to as number B22, because for some care assistants it was easier to remember his room number than his name. On another occasion, I was sat with David and asked for a plain envelope which I knew they would have as there was an office on the ward. The care assistant looked down their nose and said no. David looked at me as if to say, ‘look, see’. The care assistant said ‘who are you?’ I replied that I was David’s mum and that I’d come to see him. “The care assistant said ‘oh, sorry, I thought you were one of the patients.’ This was the treatment that was supposed to help him get better.”

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Source: Manchester Evening News, 13th July 2021

The £1.8m Salford project helping patients to leave hospital care because more than 40% don’t need to be there

Salford patients delayed on hospital wards are being helped to return to the community with a fresh start in a new home as part of a £1.8 million project.

Progressive landlord ForHousing has joined forces with Greater Manchester Mental Health NHS Foundation to tackle the long delays in people being discharged due to a lack of suitable properties.

A number of patients who have received mental health inpatient treatment in hospital or temporary mental health supported accommodation are affected and, according to NHS data, more than 40% of patients currently in mental health hospitals do not actually need to be there.

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Source: Manchester Evening News, 9th July 2021

June 2021

Bed occupancy levels at Greater Manchester Mental Health Trust continue to exceed full capacity.”

Papers discussed by Greater Manchester Mental Health Trust’s board show that whilst demand for services dropped during the pandemic, community mental health services then saw a 26pc increase on pre-Covid levels in March – ‘suppressed demand that is now coming through’. Trafford clinical commissioning group noted a similar pattern.

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Source: Manchester Evening News, 27th June 2021

Man took his own life a month after mental health team said he was no longer an ‘urgent priority’

Steven Startup killed himself weeks after he was downgraded from an ‘urgent’ priority by a Greater Manchester Mental Health Trust mental health team. Stephen’s GP had referred him for desperate help after a chat about his suicidal thoughts but the nurse who did this assessment said it wasn’t likely he would act on it.

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Source: Manchester Evening News, 24th June 2021

Death could have been prevented: Greater Manchester’s mental health trust ‘lost oversight

A heartbroken mum says she feels her daughter’s death could have been prevented if she had received the mental health treatment she desperately needed.  Olivia Garvey was found ‘collapsed and unresponsive’ at the White Lodge Hotel, in Salford, last September – six months after her last involvement with mental health services.

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Source: Manchester Evening News, 19th June 2021

Coroner will consider whether Greater Manchester Mental Health Trust could have done more to help a mother whose remains were found two years after she went missing

Inquest to be held because of questions over whether Greater Manchester Mental Health NHS Foundation Trust could have acted differently before Marie went missing. A coroner will consider whether GMMHT could have done more to help a mother whose remains were found two years after she went missing.The inquest will be heard at South Manchester Coroners Court, in Stockport, for five days from January 10, 2022. Representatives from Greater Manchester Mental Health NHS Foundation Trust will be among those giving evidence. The Coroner explained that the evidence he had seen had seen pointed to an ‘escalation of self harm’ in the run-up to Mrs Scott’s disappearance, and that there could have been opportunities to detain her which ‘could have been expected to avoid her death’.

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Source: Manchester Evening News, 17th June 2021

Grandad desperate for help took his own life after being passed from ‘pillar to post’ by Greater Manchester Mental Health NHS Foundation Trust

Coroner Chris Morris concluded Stephen Myers committed suicide following an inquest at Stockport Coroners’ Court (Image: Manchester Evening News)

Inquest heard man left ‘very upset’ when he learned from his GP, just a few days before he took his own life, that he had been discharged by the mental health team.

Manchester Evening News, 15th June 2021

Steven Myers, 49, from Wythenshawe, was found dead in room 222 at The Amblehurst Hotel in Sale on December 2 last year.

Previously homeless, he had been living in the ‘chaotic’ temporary hotel accommodation on Washway Road for eights months up until his death, the inquest heard.

An inquest into his death heard Mr Myers had been left ‘very upset’ when he learned from his GP, just a few days before he took his own life, that he had been discharged by the mental health team.

His GP referred him a second time but the inquest heard Greater Manchester’s mental health trust arranged an appointment for December 7, five days after his death.

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Source: Manchester Evening News, 15th June 2021

May 2021

Woman had fatal heart attack due to years of taking antipsychotics, inquest hears

An inquest jury has identified a series of failings in medical services following the death of a woman suffering with mental health issues for nearly 20 years. The long-term side-effects of an antipsychotic drug given 58-year-old Elaine Mylchreest caused her to die of heart problems, the hearing at South Manchester Coroner’s Court in Stockport concluded.

The 11-member jury said that the medical cause of death was myocardial ischemia – which reduces the heart muscle’s ability to pump blood – and dilated cardiomyopathy, a condition in which the heart muscle becomes weakened and enlarged. Both of these symptoms were ‘probably’ caused by Elaine’s long-term use of Clozapine which had been prescribed as a result of a treatment-resistant mental illness and had proved beneficial in alleviating distressing symptoms for many years.

The jury pointed to ‘broader failings’ in the overall treatment by medical services of Elaine, but which did not contribute directly to her death. These included not carrying out an annual electrocardiagram (ECG) tests on Elaine which might have identified the heart problems sooner. They also highlighted issues in identifying the potential link between physical health and on ongoing Clozapine treatment. Coroner Christopher Morris said that Elaine died ‘as a consequence of a recognised complication of necessary medical treatment with Clozapine’.

Source: Manchester Evening News, 13th May 2021

April 2021

Dr Alice Seabourne, medical director at GMMH defends overuse of ECT in Greater Manchester saying it is in line with NICE guidelines. Dr Alice Seabourne disputes the findings of the recent Freedom of Information audit of the use of electroconvulsive therapy (ECT) that showed that GMMHT uses ECT at the fourth highest rate in the country,

Further, GMMHT did not answer all of the Freedom of Information questions it was asked especially about whether patients gave consent before the procedure. Her grounds for not providing the requested information was that it was not held centrally and finding it would ‘create an unreasonable amount of work’ especially considering the pressures of the pandemic.

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Source: Manchester Evening News, 26th April 2021

Parents of man who killed himself after death of sister say he was ‘let down’ by GMMHT mental health services

Architecture graduate Stephen Thurm, 32, was found hanged 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.

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. 

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.”

Source: Manchester Evening News, 6th May 2021

‘Shortcomings in care’ by Pennine Care NHS Foundation Trust found as man died after absconding from hospital amid ‘deteriorating mental health’

Senior Coroner to make report to the Department of Health and Greater Manchester Health & Social Care Partnership to prevent future deaths. At the time of Martin’s death, there was a failure to conduct a detailed risk assessment in the period while a bed was sought or to agree a joint plan to manage the risk. It is probable that failure contributed to his death.

Ms Mutch, the Senior Coroner told the court: “At the time of his death, there was a failure to conduct a detailed risk assessment in the period while a bed was sought or to agree a joint plan to manage the risk. “It is probable that failure contributed to his death.”

While Ms Mutch was presented with evidence to indicate that procedures and new documents had been implemented within the two trusts, including a clearer definition of how someone is deemed to be of ‘high risk’, she feared it was not enough on a ‘national’ level. As a result, Ms Mutch said she would be making a report to prevent future deaths directed to the Department of Health and Greater Manchester Health & Social Care Partnership.The senior coroner said the report would identify the need for a ‘documented risk assessment and a documented share care plan between acute and mental health trusts’. It would also look into the issues around mental health bed shortages and a ‘responsibility’ of care.

Ms Mutch explained: “There was a very clear message from all the mental health witnesses who gave evidence that the issues of beds are ongoing in terms of patients such as Mr Gibbons who need to be placed in those beds.

“Another issue is the fact that he was assessed by a mental health trust in that mental trust area but because he doesn’t live there, it’s another mental health trust that has to take responsibility for his care That’s not an issue with the trust, they’re following a system, but that’s something that clearly isn’t right.”

Source: Manchester Evening News, 23rd April 2021

‘Gross failings’ by Greater Manchester Mental Health Trust contributed to suicide of former rugby player inquest found

Within a crisis care plan compiled in February 2020, there was specific reference to expressions of concern on the part of the family being indicative of the deterioration of the deceased’s mental health. Such concerns were raised on April 16, May 7, September 17 and November 3.

Those concerns were not followed up by the care coordinator and as such there was no face-to-face review of the deceased; the family’s concerns were not escalated; the follow-up appointment for the CTO due in October 2020 was not arranged; the deceased’s care plan made no reference to the CTO or conditions; the deceased was not seen by a mental health professional after May 2020; for reasons unknown, neither the planned care coordinator contact on May 14 and November 24, nor any psychiatric review after April 9 took place; supervision was either inadequate or non-existent.

All of which amounted to gross failings and as such, sub-optimal care.

Source: Manchester Evening News, 23rd April 2021

March 2021

A jury has found mental services were ‘fundamentally flawed’ in their handling of a beloved son and brother who killed himself in a hospital ward and that a lack of communication between mental health teams, particularly after Ashley’s most recent admission, had partly contributed to his death.

Ashley’s family has criticised the mental health care their loved one received, saying that health care teams were ‘reactive instead of proactive’ and had a habit of ‘only intervening at the point they have to’ Brother Christopher also raised concerns that Ashley’s care ‘was too clinical’, adding that he felt medics ‘did not take the time to get to know’ their patient.

The jury found that the process of discharging him from the Rochdale hospital had been ‘wholly insufficient’ and that there had been a lack of documentation relating to his condition for medics to use. They also concluded that the ‘communication and handover documentation was fundamentally flawed’, and that this needed to be improved.

Coroner Lisa Judge said that she would likely have issued recommendations for change within the mental health services that cared for the young artist, but staff within the hospital had already undertaken a review and made changes.

“What is apparent is that, as a result of the root cause investigation, a formal document was prepared with recommendations that the authors had and all of those recommendations have been taken forward by the trust,” the coroner said.

Source: Manchester Evening News, 11th March 2021

February 2021

Father of Emily Jones hits out as review of GMMHT finds actions of patient that killed his daughter ‘could not have been predicted

Despite the evidence of previous violence towards others, threatening behaviour involving a child and the lack of medication monitoring, an internal GMMHT review concluded that the attack on Emily ‘could not have been predicted or prevented’.

Emily’s father, Mark Jones, has been heavily critical of the mental health services and has slammed review into Skana’s treatment. He says he is waiting for a second investigation, already announced by NHS England, which is set to be launched soon.

“It clearly highlights major failures in GMMH’s systems and a lack of communication,” Mr Jones said.

“The lack of communication was probably down to so many people being involved in Skana’s care. She was passed from pillar to post, and as a result, some clinicians were unaware of the threat she posed.

“The failings are clearly and comprehensively addressed in their review but they still continue to relinquish all responsibility for the actions that lead to my daughter’s death. I therefore welcome the further imminent review by NHS England. I await their findings and will act on it accordingly in due course.”

Source: Manchester Evening News, 8th February 2021

Melanie Hogben fell to her death from Arndale car park after battling mental health issues, inquest hears

Melanie, who leaves behind a son and a daughter, had been struggling with mental health issues for several years. She was sectioned under the Mental Health Act just months before her death after battling Schizoaffective disorder. 

An inquest into her death at Manchester Coroners’ Court heard she was discharged from a mental health unit in June 2018.

Melanie was admitted to the Moorside Unit at Trafford General Hospital, which is run by the Greater Manchester Mental Health NHS Foundation Trust, on March 9, 2018.

During her admission, a consultant psychiatrist changed her medication to a depot injection for two weeks to ‘improve her symptoms’, the inquest heard.

Her partner Tony said they were ‘concerned’ by the injection because of the side effects she suffered.

By the time Melanie was discharged on June 13, her condition had improved and she was put back on her previous anti-psychotic medication.

She had regular visits from a care coordinator until the beginning of August, but wasn’t then seen or contacted by any mental health professionals until October 18.

That care coordinator went off sick before leaving her position, the inquest heard.

But despite being classed as ‘high-priority’ after being sectioned, Melanie wasn’t given a new care coordinator until August 22.

Her new coordinator Wilma Martin-Lawrence told the inquest she was on a two-week holiday at the time Melanie was added to her case load of 28 service users.

The inquest also heard how she was unable to work in her capacity as care coordinator on 21 out of 43 days at that time due to other professional commitments.

Ms Martin-Lawrence was unable to make contact with Melanie until the beginning of October after she had contacted mental health services to ask who her care coordinator was.

Melanie took her life just over two weeks later.

A serious incident review was carried out by the Greater Manchester Mental Health NHS Foundation Trust. It showed that there were ‘significant staffing issues’ at the time of Melanie’s death. Daniel Cottam, operational manager for mental health services in central Manchester, told the inquest the team ‘was under significant pressure at the time’.

Source: Manchester Evening News, 3rd February 2021


December 2020

The tragic mistakes that sealed the fate of Zak Bennett-Eko

Zak Bennett-Eko killed his son and was found guilty of manslaughter by reason of diminished responsibility. The presiding judge at the Lowry Nightingale Court had one important question of his own – exactly how did it come to this?

There were some answers revealed in court, as three psychiatrists took to the witness box to try and make sense of the incomprehensible. They told a story of a severely mentally ill man – aware of his spiralling condition – ‘slipping through the net’ and being ‘failed by the system’ at every turn, to use the judge’s own words.

The judge addressed Bennett-Eko, though he was not present in court, as he sentenced him to a hospital order which would confine him to a secure prison hospital.

“The regular trips you made to A&E show that you made genuine and sustained attempts to seek professional help,” said Judge Fraser.

“You were trying, as best you could in this respect, and you expressly asked to be sectioned.

“Your difficulties in communicating would have made it a lot more difficult for doctors in a busy A&E department to recognise your mental state, and sadly, on each occasion you presented at the hospital the help you needed was not available.

“You have serious medical conditions requiring urgent, intensive and long-term treatment.

“However, it is not the only failure of the system in your case. You seem to have slipped through the net in terms of care for your mental illness, which with hindsight was far more serious than was realised at the time.”

Although the young dad came off his medication, it was clear he had enough insight to seek help when he felt his condition relapsing in the weeks before the killing. Altogether, Zak Bennett-Eko went to A&E six times in 2019, begging for help with his deteriorating mental health. On one occasion, he specifically asked medics to section him.

Source: Manchester Evening News, 22nd December 2020

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