Staff Skipped Checks And Said A Vulnerable Young Woman Was Safe. Days Later, She Was Dead

Warning: The pursuing article contains specifications astir termination which immoderate whitethorn find distressing

Cerys Lupton-Jones pauses betwixt 2 doorways.

One doorway leads into a broadside room successful nan Manchester intelligence wellness portion wherever she's a patient. The different leads into a toilet.

The 22-year-old had tried to extremity her life conscionable 20 minutes earlier - but nary unit are seen connected nan CCTV footage from wrong nan unit.

She hesitates for astir 30 seconds, stepping backwards and forwards. Then she enters nan toilet and shuts nan door.

The adjacent clip she is seen connected nan footage, doctors and nurses are fighting to resuscitate her.

Cerys dies 5 days later, connected 18 May 2022.

A coroner has concluded that immoderate of nan attraction Cerys was fixed astatine Park House, which was tally by nan Greater Manchester Mental Health NHS Foundation Trust, was a "shambles".

Staff were meant to beryllium checking connected her each 15 minutes.

But nan past recorded study - astatine 15:00 - had been falsified, saying she had been seen successful a corridor. CCTV shows astatine that point, Cerys was already successful nan toilet wherever she would fatally harm herself.

A unit personnel who was expected to beryllium looking aft her has now admitted to falsifying these records.

Zak Golombeck, coroner for Manchester, said that if personification had stayed pinch her aft nan earlier effort to return her life, what followed whitethorn ne'er person happened. He said neglect was apt to person contributed to her death.

Campaigners are calling for an enquiry into nan number of deaths astatine nan intelligence wellness spot and judge nan services are successful crisis.

Greater Manchester Mental Health Trust said it "failed her that day, and we are truthful very sorry that we did not do more".

Cerys's parents, Rebecca Lupton and Dave Jones, picture their girl arsenic a loving young female who would do thing for her friends. She was studying to beryllium a caregiver and was months distant from completing her degree, pinch a occupation lined up.

She was autistic and had besides struggled pinch her intelligence wellness since her teens.

Her family, who lived miles distant successful Sussex, opportunity nan pandemic and nan simplification successful organization intelligence wellness support exacerbated Cerys's problems.

The inquest was told Cerys had tried to return her life successful nan days moving up to her death, spending clip successful A&E.

She was past readmitted to Park House and put connected one-to-one observations for a short time. Later, she was expected to beryllium checked by unit each 15 minutes.

The inquest heard how, astatine astir 14:35 connected 13 May 2022, Cerys was recovered successful a toilet by Mohammed Rafiq, a wellness support worker who had been assigned to cheque connected her. Cerys had tried to bent herself.

Mr Rafiq and nan work nurse, Thaiba Talib, intervened.

However, nan inquest heard nan 15-minute observations were not past accrued and unit had nary due speech pinch her.

The caregiver told nan inquest she did not judge Cerys meant to earnestly harm herself.

She told nan coroner she chose not to summation observations connected Cerys because she did not want her to consciousness punished, arsenic she did not for illustration being nether observation.

When asked by nan coroner if she should person gone pinch Cerys to her room aft nan incident and cheque she was safe, Ms Talib answered: "In hindsight, yes."

Damning CCTV from wrong nan portion was described infinitesimal by infinitesimal successful court.

It showed Cerys going into nan ward plot astatine 14:42. The study record, which says astatine 14:45 she was successful her bedspace, was described by nan coroner arsenic "not accurate".

At 14:54, Cerys walked into different toilet connected nan ward and closed nan door.

Yet Mr Rafiq told nan coroner he remembered seeing Cerys astatine 14:57. He wrote successful nan study notes that he had seen her astatine 15:00 "along nan corridor, looking flat-faced". He past went connected a break. In reality, Cerys was still successful nan toilet.

The coroner told Mr Rafiq that his recollections were wrong, and that he had "falsified" nan study records. Mr Rafiq responded: "I'm acrophobic so".

Mr Rafiq said different unit had shown him really to grounds observations each 15 minutes, moreover if he hadn't done them astatine that time. "That's really they did it and that's really I did it", he told nan court.

A caller support worker took complete nan observations astatine 15:00. There was nary verbal handover and, according to Mr Rafiq's notes, Cerys had conscionable been seen.

The CCTV shows nan caller support worker checking connected different patients. At 15:15 she looked for Cerys.

She could beryllium seen becoming progressively hopeless arsenic she searched nan communal areas and ran on nan corridor.

At 15:19, she tried nan doorway to nan toilet, utilizing a maestro cardinal to unlock it. She recovered Cerys wrong and instantly raised nan alarm.

By that point, 25 minutes had passed since Cerys went into nan toilet. She died successful infirmary connected 18 May, 5 days later.

The coroner said location was a gross nonaccomplishment by Ms Talib to supply "basic aesculapian attraction to a personification successful a limited position".

He besides recovered location was a civilization of falsifying records connected nan ward.

The coroner said it was not clear what Cerys's volition had been. In a communicative conclusion, he recorded that neglect had contributed to her death.

"I knew it was bad," Cerys's mother Rebecca told nan BBC, "but listening to nan grounds highlighted rather really mediocre nan attraction was."

Her father, Dave, says erstwhile Cerys was sectioned and taken to nan infirmary astatine nan commencement of 2022, they believed it would support her safe and thief her get better. "In fact, it conscionable made everything worse," he says. "It was nan incorrect environment."

"Cerys was a wonderful, awesome young person. We consciousness that she would beryllium present coming if she'd been fixed amended attraction by Manchester Mental Health Trust," Rebecca said extracurricular court, aft nan coroner gave his conclusion.

Dave described nan disbelief and anger arsenic difficult to put into words. "We request much backing for intelligence wellness services, much staff, amended training and overmuch amended oversight."

Immy Swithern was a diligent astatine nan aforesaid clip arsenic Cerys. They became adjacent friends. She says they tried to make nan champion retired of a bad business and would talk each day.

She besides claims immoderate unit regularly grounded to transportation retired 15-minute information checks, truthful they tried to look retired for each other.

"I was location to get better, and I was location to person thief pinch that," she says. "Instead, I was perpetually checking connected people. On that ward, I deliberation that is nan astir frightened I've ever felt successful my life."

Park House intelligence wellness portion has since closed. It was replaced by a caller £105.9m infirmary successful November 2024.

The NHS spot said it had "significantly improved" its proviso of attraction and it was grateful to nan coroner for "acknowledging nan activity that has been done to forestall thing of this quality from happening again".

But campaigners declare intelligence wellness services successful Manchester are successful crisis.

Responding to Tuesday's inquest verdict, nan Communities for Holistic, Accessible and Rights-based Mental Health (CHARM) group, says: "It is devastating to perceive of yet different young personification losing their life arsenic a consequence of neglect and mediocre care."

The group says it is owed to meet Mayor of Greater Manchester Andy Burnham this week to telephone for a statutory enquiry into nan deaths and nan financial situation successful nan city's intelligence wellness services.

In October 2022, 5 months aft Cerys death, an undercover BBC view programme exposed bullying and nan mistreatment of patients astatine nan mean unafraid Edenfield centre, which was besides tally by GMMH.

As a result, an independent reappraisal was commissioned by nan NHS and published successful 2024.

It recovered a "closed culture" astatine GMMH. It besides raised concerns astir nan number of deaths by ligature.

In 2022, 19 group took their ain lives by hanging connected intelligence wellness units successful nan UK, 5 were GMMH patients, nan spot itself said that meant it had 26% of each specified deaths successful nan full country.