Yahoo News 'My Charlie lost his life while supposedly in a place he was being cared for - I will fight for justice'
Charlie Millers' mum has vowed to continue her 'fight for justice' - and has called for a public inquiry into an NHS trust - after an inquest jury concluded he did not intend to take his own life and identified failings in his care.
The 17-year-old trans boy from Stretford, Trafford, died five days after he was found unresponsive in his room on mental health unit Junction 17, at the site of the former Prestwich Hospital, run by Greater Manchester Mental Health Trust (GMMH) late in the evening of December 2, 2020.
On Thursday (April 25), a jury said a lack of one-to-one, constant nursing care likely 'contributed to his death'. Jurors determined Trafford council services did not communicate with each other effectively enough and did not provide Charlie's mum the 'practical support' she needed as his mental health worsened, without enough help in the community.
They also said he should have been the subject of a 'care protection plan'. Jurors said GMMH's observation system, where staff checked on Charlie during his stays on wards including at the time he was fatally injured, was 'not robust enough' and was undertaken 'inconsistently at best'.
GMMH said 'a wide range of actions have already been taken to improve inpatient mental health services both in response to Charlie's death, and as part of [a] wider improvement plan'.
The senior coroner who presided over the inquest, Joanne Kearsley, told jurors she would write to the Home Office, the Department for Health and Social care and agencies in Greater Manchester for their responses to the case, adding: "If there is going to be effective learning from these deaths, it must be done quickly."
'Shocked... beyond shocked'
Following the hearing, Charlie's mother Samantha told the Manchester Evening News: "I am shocked... in fact, beyond shocked. I will continue to push in every possible direction. I will look into the possibility of taking legal action against the trust and I want Greater Manchester Police to re-open their inquiry.
"The inquest heard there was insufficient evidence for them [GMP] to do a thorough investigation. I believe they should look at it again.
"I think the trust and Trafford council have failed. Given the fact there were three deaths of young people in nine months at the same site, we need to call for a public inquiry."
As previously reported by the Manchester Evening News, three young people died within nine months at the Prestwich site. Rowan Thompson, 18, died in October 2020; followed by Charlie in December 2020; and Ania Sohail, 21, in June 2021.
In October 2022, a jury at Rowan's inquest concluded a lack of timely communication surrounding blood test results contributed to their death. They ruled that amounted to 'neglect', meaning 'a gross failure to provide basic medical care' as a result of the failure.
Samantha added: "It is the same story over and over again. I think the orders issued by coroners - to prevent further deaths - are not changing anything. I have no doubt the coroner in Charlie's case will put everything into her [prevention of future deaths] report. But I'm fearful of it happening again.
"Today, I feel like I have just lost Charlie. I have had no time to grieve as I have been so focused on trying to find out the answers as to how he came to lose his life. We waited 14 extra months for this inquest. I feel sad that my child was allowed to lose his life while supposedly in a place he was being cared for.
"I will fight for justice. I will take this as far as I can, I will never give up - even if it takes years."
'We will never know the truth'
Charlie was found unconscious with injuries caused by a ligature. At the time, he was on a strict observation regime. He was supposed to be checked on every five minutes, the inquest heard.
Charlie's medical cause of death was given as 'hypoxic brain injury'. The jury said ADHD, 'mixed conduct' and autism spectrum disorders - and an emerging emotionally unstable personality disorder - were 'background features' to his cause of death. Self-harm was a symptom of his mental health diagnoses, jurors added.
They concluded Charlie did not intend to take his own life. GMMH's investigation was described as 'lacking' in court as bosses failed to speak to all staff members working on the ward at the time when the teenager was fatally injured.
Mental health unit managers were told to audit observations being done on patients staying on wards after fears they were not being done, only for those audits to also go uncompleted, the court was told. GMMH managers were instructed to carry out daily audits of the regular checks being carried out on patients by ward staff, the inquest heard.
The audit programme followed concerns in October 2020 that those regular checks, where patients are observed a set number of times an hour in accordance with their condition, were not accurate or simply not being done. It was later found, the court heard, 'there was no evidence' some of the audits themselves were ever done.
Charlie struggled with his mental health from around the age of five. Things worsened through his teenage years. This manifested itself in serious self harm; and thoughts of wanting to die and hearing voices, including a voice he named 'X', which told him to harm his family or himself.
Samantha added: "There were gaps in the evidence. We did not have statements from key witnesses and some of those key witnesses were not interviewed until approximately two years after Charlie's death.
"We will never know the truth of what happened to Charlie because the accounts are so inconsistent and there is not documentary evidence that five minute observations were properly completed.
"We are deeply concerned that GMMH still has not learned and does not have a more robust process in place for ensuring that observations are carried out according to policy."
'We are deeply sorry'
Dr Arasu Kuppuswamy, chief medical Officer at Greater Manchester Mental Health NHS Foundation Trust, said: "This was a tragic case, and our thoughts remain with Charlie’s family. We fully accept the inquest's findings and jury's conclusion.
"A wide range of actions have already been taken to improve our inpatient mental health services both in response to Charlie's death, and as part of our wider improvement plan.
"This includes strengthened clinical leadership, new approaches to observing patients, training for staff, and weekly audits with learning shared across GMMH.
"We are developing a new electronic system to record patient observations digitally that will enhance the assurance process. This will feed into a central system to reduce errors, ensuring records are always up-to-date and available for care professionals looking after a patient.
"We know there is more work to do and will implement the coroner’s recommendations and continue to work with partners to improve care.
"We understand nothing will bring Charlie back and are deeply sorry for Charlie's family and friend's loss."
