How a Manchester mental health ward neglected a suicidal patient

Dear readers — today’s story covers the inquest into the death of Charlotte Sophia Parry, a 27-year-old who tragically took her own life while on an acute psychiatric ward in Wythenshawe in 2022. The inquest looked at whether neglect by Greater Manchester Mental Health Trust contributed to Charlotte’s death. The piece features references to suicide and self harm and discretion is advised. If you are having thoughts of suicide or are concerned that someone you know may be, find help here.

We have made the piece free to access as we believe hearings like this, in which vulnerable people have died while in the custody of public bodies, are in the public interest. However, if you would like to support this type of journalism you can sign up by clicking the link below.

It was Friday afternoon at Manchester coroner’s court and everybody was crying. Eleven jurors, three lawyers, two clerks, one family and the coroner himself could not fight back the tears. On large plasma screens set up in each corner of the room, a slideshow of photographs was being played. The photographs were of a woman named Charlotte Sophia Parry.

Paul Appleton — the clean-cut coroner whose rote questioning of witnesses was the steady drumbeat behind all of our lives that week — took off his black-rimmed glasses. “It’s not really appropriate,” he said to the family, “I’m sorry.” The photos of Charlotte showed a side of her life that to the jury had been a mystery. Aside from a short statement from her mother — it hadn’t heard evidence pertaining to what made Charlotte happy, or evidence pertaining to her happiness in general. 

Instead they were to understand how Charlotte, a 27-year-old former occupational therapist, came to take her own life while on Bronte ward, an acute psychiatric ward in Wythenshawe. Most inquests are straightforward: the coroner is left to question witnesses and experts about how someone came to die and make a conclusion. But when someone dies in the custody of the state, in a hospital or a prison for example, the nature of an inquest changes. A jury is introduced to decide whether the public body tasked with keeping that person safe neglected to do so. 

Charlotte was born on 9 June 1994, one minute after her twin sister, Alex. Growing up, she was drawn to caring for others. When she was nine she helped care for her grandfather after he had a stroke, encouraging him to do exercises and, her mother told the court, playing an instrumental role in nursing him back to health. After that, she volunteered as a carer and went on to study at Liverpool University. She worked in Liverpool after qualifying, eventually moving back to Manchester. 

It is unclear exactly when Charlotte began to struggle with her mental health. The court heard that she had attempted suicide in 2010, when she would have been around 16, and she self-harmed while at university. By 2020 she had been in a traumatic five-year relationship, terminated a pregnancy, and had seen another relationship with a man she expected to marry break down. 

During the pandemic things got worse. She had a series of cognitive behavioural therapy (CBT) sessions between November 2020 and March 2021, and was then referred to home-based treatment after presenting at A&E with suicidal ideation. When these thoughts became unmanageable, she would self-harm.

By the summer of 2021, she was sectioned under the mental health act and living on Medlock ward, a 21-bed female acute unit in Trafford General. She had been diagnosed with emotionally unstable personality disorder (EUPD) and obsessive compulsive disorder (OCD). 

Acute wards are distressing places. Designed to manage patients in crisis, they work as a stop gap while more suitable treatments at specialist facilities or rehabs are arranged. A protracted stay can do more harm than good. This was the case for Charlotte. 

There is no licensed medication for people diagnosed with EUPD. The national institute for clinical excellence recommends psychological treatments like CBT or dialectical behavioral therapy — a kind of talking therapy. But Medlock ward, where Charlotte was first admitted, had no psychologist. According to Dr. Jyotsna Srivastava, a consultant psychiatrist on the ward when Charlotte was there, it was suitable for risk management but not for psychological input. Nevertheless, Charlotte would spend around two months on the ward. Although staff said this, relative to other stays, was not unusually long.

In October she was transferred to Bronte ward, a 33-bed acute unit in Laureate House, on the grounds of Wythenshawe hospital. Bronte ward was closer to Charlotte’s home and family, and had better access to psychologists. Susan Trotter, a care co-ordinator — a kind of social worker for mental health patients — told the inquest that Bronte was better run than Medlock in terms of staffing and liaison: “At Medlock it was hit and miss.”

One of her responsibilities as care co-ordinator was to get Charlotte off Bronte ward and onto a placement where she could access the specialist care she needed. Charlotte was declining on acute wards, she was taking time from group classes to stand facing a wall, sometimes hitting her head off of it. In a statement, one staff member recalled a section of bloodstained wall in Bronte ward’s courtyard and called it “her spot”. 

On 29 October it was agreed at a ward meeting, which Trotter joined remotely, that Charlotte would be transferred to a longterm specialist placement. Trotter was to oversee the process, sending applications to private companies and arranging the necessary funding.

But this didn’t happen. Trotter sent applications to three providers. One asked for more information, and the second ended up under investigation and therefore was no longer an option, she said. But in December, a third provider accepted Charlotte. However, even though Trotter had got a bed reserved, the panel she was meant to secure funding from said they never heard from her.

“Did you send that form to the funding panel,” Appleton asked, with the funding application document on a large screen showing behind him. “Because they said they didn’t receive it.”

“Well, they did.” Trotter said. 

“Date?”

“I don’t know, it was a long time ago.”

“You’re positive you sent it to the funding body?”

“Yes.”

“One potential view is you didn’t send the application to the panel, what would your response be to that?”

“I did.”

There was no evidence that Trotter sent the application. It meant that Charlotte stayed on a ward where she would make repeated acts of self-harm. Though, as multiple witnesses attest, there was no way of saying the specialist placement would have improved things. Srivastava, the psychiatrist, agreed that Charlotte’s suicidal ideation was “chronic” when asked by Greater Manchester Mental Health Trust’s (GMMH) lawyer. “Charlotte will continue to attempt to take her life until she is successful,” one contemporaneous note read. But the point for the family is, they’ll never know now.

As more witnesses took the stand the picture of Charlotte’s time on the ward became more complicated and jarring. Charlotte’s occupational therapist Rebecca Edgeley — who was so impacted by their time together, as fellow OTs, that she cried giving evidence — told the court that on 23 December 2021, Charlotte went to Lidl on supported leave to buy ingredients to make a cheesecake. She made it in the ward kitchen and was proud. Then a ward staff member would tell the court that, on that same day, Charlotte attempted to hang herself from a chest of drawers in her room. 

Charlotte frequently used the chest of drawers to self-harm in this way (it is journalistic convention not to explain methods of suicide and self harm in too much detail, so we will not be doing so here). Some nurses had not come across this before, and it was noted in Charlotte’s clinical documents. One incomplete list of self-harm incidents during Charlotte’s time on the ward detailed 35 ligature attempts, though not all used the drawers.

On 27 December, the drawers were removed from Charlotte’s room as they had become too great a risk. In the weeks after, there was a decrease, though not an eradication, in ligature attempts. During this time, Charlotte’s level of observation was also lowered from once every fifteen minutes day and night to once every fifteen minutes during the day and once every hour overnight. Charlotte became distressed by this, worried she wasn’t receiving adequate care. But the ward’s manager, Carl Gale, outlined how keeping observations high can institutionalise patients with EUPD. On 28 January, two days before her death, Charlotte was dropped to hourly observations during both day and night. 

Around the time her observations were reduced, the drawers were also returned to Charlotte’s room. The discussions around the decision to return the drawers were not well documented, the jury found. Shahid Hussain, the ward’s consultant psychiatrist, and Gale, the ward manager, had no part in the decision. There was also no evidence of it being discussed at a multidisciplinary meeting. 

Emma Ager, the nurse primarily responsible for Charlotte's care, said she spoke to Charlotte on the day the drawers were returned. Charlotte wanted the drawers back, and she and Ager talked about the risks involved and why the drawers had been taken away in the first place. Ager said Charlotte had been more stable at this time, and her mood was bright.

There was a tension in the court when Ager was giving her evidence. She argued, like others, that the return of the drawers was an example of “positive risk taking” and was based on the principles that dictate mental health care as something that should be as unrestrictive as possible while remaining safe.

“Would you accept it was a mistake to return the drawers?” Asked Lily Lewis, the Parry family’s lawyer.

“No.”

On 30 January Dr Benjamin Grice, a junior doctor in his second year out of university, was on a placement in liaison psychiatry at Manchester Royal Infirmary. He clocked in at Laureate House at 9am as the junior doctor on call. At 20:51, he received a call from the ward that a patient was in cardiac arrest. It was his first time responding to a cardiac arrest, and he ran down to the ward from the on-call office.

A little over three minutes earlier, a support worker named Nualanong Phonprasan knocked on Charlotte’s door and got no answer. She unlocked the door, entering to find Charlotte had used the drawers to hang herself. She raised an alarm, but did not make the cardiac arrest call, which had to be done from a phone in the nursing office and would have alerted Grice. 

Three minutes would pass before Grice received the cardiac arrest call. By the time he entered the room, Charlotte was lying on her back and blue in the face. There was no pulse or visible sign of breathing. The resuscitation kit he was given didn’t have the kind of intubation device he would usually expect, the first defibrillator he used had technical difficulties, he could have delegated more tasks to other staff before the registrar and crash team arrived. As he gave his evidence, Charlotte’s father sat wide-eyed with his hand over his mouth. 

“I can say it wasn’t perfect,” Grice said from Australia, where he now works, via video link. “In an ideal world, the airway would have come under quicker control, while a defibrillator was attached with good, quality chest compressions.” A later witness, Dr Alan Grayson, a consultant in emergency medicine, found that none of these issues could be said to have caused Charlotte’s death without knowing the exact time she had tied the ligature. And, because she hadn’t been observed for an hour when she was found due to her observations being relaxed, it's impossible to say. It’s likely, Grayson said, that “Miss Parry had already suffered irreversible brain damage,” when she was discovered. 

Charlotte was transferred to Wythenshawe Hospital and spontaneous circulation was achieved. But on the 6 February care was withdrawn and she died. Charles Alexander Wilson, the pathologist, found the cause of death to be ischaemic brain damage as a result of pressure to the neck.

One of the last times Charlotte was seen alive by staff is when she left her room for a walk down the corridor. CCTV shown to the court shows her, around an hour before she was discovered, passing nurses and other staff on the corridor who are on their phones. 

One healthcare support worker looked up from her phone for a second but did not engage with Charlotte or speak to her before looking back at her phone. There was a debate in court over whether this counted as an observation, in that it technically established Charlotte was alive. When Lewis, the lawyer, was questioning ward manager Gale about whether nurses should be using their phones on the ward (they’re not), the support worker in question could be seen mouthing something to the other staff waiting to take the stand.

“Did she say I was on my phone?” 

The others nodded. 

“I was on my phone? Oh, fuck.”

The kind of bag Charlotte used was left on the witness stand in the latter days of the inquest. The ward had a blanket ban on plastic bags, but other bags were considered on an individual basis. There was no documented risk assessment related to the bag Charlotte used to kill herself.

In its conclusion, the jury said that the lack of risk assessment related to the bag, and the chest of drawers not being identified as a ligature risk, contributed to Charlotte’s death. Other factors, like it taking three minutes for ward nurses to call Dr Grice, were found not to have contributed to Charlotte’s death but were still deemed significant. 

Appleton, the coroner, left the option open for the finding of neglect. The threshold to do so is quite high. It means the evidence suggested there had been a gross failure to provide basic care. “For a jury to find that is a very stark and powerful finding,” Lewis, the lawyer, told me afterwards. And in Charlotte’s case, they did find that neglect contributed to her death. 

In a statement to The Mill, the Parry family said: “We as a family are absolutely devastated. For the jury to conclude neglect by GMMH contributed to Charlotte’s tragic death makes this even more unbearable. To date, we have not received any sort of apology for their significant and systematic failures including numerous critical findings in relation to Charlotte’s care.”

When we approached GMMH for comment, asking for their response to the family’s statement and whether they would apologise, Mike Hunter, Interim Chief Medical Officer said:

“On behalf of GMMH, I would like to say how truly sorry we are for the failings in the care and treatment we provided for Charlotte Parry. The death of a loved one is always a tragedy, but to learn that neglect contributed must have been devastating for Charlotte’s family and loved ones, and we will be contacting them personally to reiterate our apology.

“Since Charlotte's death in February 2022, under the Trust’s new leadership, we have been working closely with NHS England, our commissioners and our regulators to create better, safer and well-led services. Our Trust-wide recovery plans address all nine recommendations for GMMH from Professor Shanley’s independent review published in 2023.”

 “We would like (to) say again how very sorry we are that we did not do more for Charlotte and her family.”