Charlotte Sophia Parry

This is a media release by Farleys, reshared by INQUEST

Before HM Area Coroner Paul Appleton
Manchester Coroner’s Court
Opens Monday 31^st March 2025 (with evidence commencing on Tuesday 1^st April 2025)
Scheduled for 2 weeks

Charlotte was 27 years old when she died from injuries sustained whilst a mental health patient on the Bronte Ward, Laureate House, in the grounds of Wythenshawe Hospital on 6^th February 2022. An inquest will now resume to examine the circumstances and care provided by Greater Manchester Mental Health NHS Foundation Trust.

The Trust has received significant local and national attention following a BBC Panorama investigation of the Edenfield Centre in Prestwich, run by GMMH, and the Independent Report commissioned by NHS England in 2024 which looked at various areas of concern within the Trust.

Charlotte was a twin born just one minute after her sister with whom she shared an incredible bond. From an early age it was clear Charlotte had a passion for helping others and, at the age of 9 years old, was instrumental in helping her Grandad to recover from a devastating stroke. Through Charlotte’s love, care, and compassion for others, her grandad was able to walk again. Unbeknown to her parents, at this young age Charlotte had already chosen her career path and went on to study Occupational Therapy at Liverpool University.

Charlotte loved life. She was a people person and loved to travel. Most of all Charlotte loved her family and her nephew was the light of her life.

Sadly, Charlotte struggled with her mental health and had sought input and help from professionals over a number of years. Following a significant deterioration in her mental health, Charlotte was transferred to Bronte Ward under S3 MHA 1983 on 19^th October 2021. The intended plan had been for her to be transferred to a specialist hospital for individuals with a diagnosis of personality disorder. Assessments and funding were being sought for her but sadly she died prior to any transfer taking place.

In the months following her admission to the Bronte Ward, Charlotte attempted to take her own life on multiple occasions. Over the course of 7 days in the November period, there were five documented incidents of Charlotte tying a ligature. Charlotte’s ligature attempts continued right up to her death. On 30^th January 2022, Charlotte was found by a nursing assistant having ligatured. The incident involved a chest of drawers that had previously been removed following a ligature attempt less than a month earlier, but were returned shortly before Charlotte’s death.

Charlotte’s family have serious concerns about the care she received whilst an inpatient on the Bronte Ward.

The Article 2 inquest will be held before a jury and will consider a number of issues, including the care and treatment provided to Charlotte by GMMH and whether healthcare staff failed to take reasonable steps to prevent her death. This will include whether ligature risks were managed appropriately.

In January 2024, an Independent Review of GMMH commissioned by NHS England was published. The investigation and its findings looked at various areas of concern regarding the quality of care within the Trust, including in relation to the management of ligature risks for in-patients. That report noted that, in 2022, 26% of all suicides involving ligatures on inpatient wards in the UK took place in GMMH, and that GMMH accounted for approximately 11% to 15% of all inpatient deaths in England. Written evidence will be heard at Charlotte’s inquest from Professor Oliver Shanley OBE, Chair of the review. 

The CQC has also repeatedly raised concerns in its inspections of GMMH acute wards. On 20^th June 2024, the CQC served section 29A warning notice on the Trust for “lack of effective governance systems, ligature risks and fire safety concerns, medicines not managed safely, ward security systems not consistently keeping people safe, infection prevention and control risks and staff not up to date with mandatory training”. The CQC can serve a Warning Notice when concerns are identified across either the whole or part of an NHS trust, and there is a need for significant improvements in the quality of health care. This includes concerns that are probably systematic and affect the entire system or service, rather than being an isolated matter, and/or result in the risk of harm or actual harm.

The family are represented by Kelly Darlington of Farleys Solicitors, and Lily Lewis of Garden Court North Chambers.

Other interested persons represented are the Greater Manchester Mental Health Trust (‘GMMH’) who are the service provider for Laureate House, Wythenshawe Hospital.

- Ends –

Notes to Editors

NHS England investigation

In November 2022, NHS England commissioned an independent review of GMMH. This was done in response to failings in care given to patients at the Edenfield Centre in Prestwich, Greater Manchester. Professor Oliver Shanley OBE was appointed as Chair of this independent review in January 2023. He published his report on 12^th January 2024.

The review was commissioned in order to investigate specific concerns in relation to failings in care at the Edenfield Centre in Prestwich but also to look at the operation of the Trust more generally.

The majority of the investigation took place between February and September 2023 [p.18], the year after Charlotte died. Professor Shanley and his team spoke to over 400 individuals about their experiences of the Trust, including staff, patients, families, and carers. They also undertook a series of visits to both Edenfield and other Trust services, and reviewed a wide range of documentation from the Trust and its partners. 

The report identified a number of concerns relating to the leadership and governance of the Trust, as well as specific findings relating to inpatient deaths through suicide and the management of ligature risks, at pages 75 to 81 (paragraphs 9.33 to 9.65).

CQC

In 2021, the CQC carried out an inspection of GMMH’s “Acute wards for adults of working age and psychiatric intensive care units”.

The inspection took place from the 6^th to 7^th September 2021. Although the CQC inspectors did not visit the Bronte Ward, they visited a sample of eight wards across five of the seven locations where the trust’s acute wards for adults of working age and psychiatric intensive care units (PICU) were located [details at p.2 of report if required].

In its report of that inspection, published 26^th November 2021, CQC did not rate the service at the inspection, however they found that the previous rating of “requires improvement” to the question “Are services safe” remained.

The overall findings of the CQC following this inspection (with general relevance) included that [p.2-3]: 

• The wards did not all have up to date and recently reviewed ligature risk assessments. Staff on two wards could not locate the ligature risk assessments at the time of the inspection.
• The service did not always have enough nursing staff, who knew the patients or received basic and essential training to keep patients safe from avoidable harm.
• The environment on Poplar ward was not clean on the first day of inspection and space on the ward was limited for patients.
• It was not clear that immediate concerns or learning from incidents was shared across the locations, although local learning and reviews were taking place.

At pages 3 to 4, the report made a number of relevant findings relating to the safety of ward environments. At page 10 the CQC identified a number of areas for improvement.

In 2022, the CQC carried out a further inspection of acute wards for adults of working age and psychiatric intensive care units. This inspection took place on 13^th June to 7^th July 2022, after Charlotte’s sad death. CQC inspectors visited mental health core services including acute wards for adults of working age. This included the Bronte Ward at Laureate House.

Following the inspection, the CQC took enforcement action against the Trust. The CQC served CMMH with a Section 29A Warning Notice because the quality of health care provided required significant improvement in some areas identified during the inspection. The Warning Notices set out a legally set timescale for the provider to become compliant [p.3].

In its report, the CQC made a number of relevant overall findings in relation to the Trust [p.3 – 4] and directed the Trust to take a number of actions to improve at a Trust-wide level [p.7 – 8].

In relation to “Acute wards for adults of working age and psychiatric intensive care units”, overall, services were rated “Inadequate” in answer to the question “Is the service safe?”.

The following findings were made in relation to the safety of wards [p.73 – 74]:

“We had significant concerns during this inspection that people were at risk of avoidable harm across these wards, particularly in relation to fire safety and ligature risk audits and actions.

…

“We had significant concerns about the assessment and management of ligature risks. In the last 12 months, there had been serious incidents of harm relating to ligature use, including three in-patient deaths. [Charlotte’s death was one of these cases]

“There were potential ligature anchor points in the services, including bathroom and bedroom fittings and furniture. Staff did not know about all potential ligature anchor points and did not mitigate the risks to keep patients safe. This meant that the facilities were unsafe.

“Wards had ligature risk assessments and audits in place which identified some but not all ligature risks. The risk assessments did not list all ligature risks to support their identification to ward staff which meant they were unable to adequately monitor them. Where ligature risks were identified, there were no specific actions to guide staff or mitigate. Ward staff had access to these assessments but on some wards, these were out of date printed copies with up to date versions held on the electronic system that not all staff had access to.

“Assessments and audits did not include clear timescales for removal or mitigation of risk, they did not state who was responsible for actions which meant there was little oversight. Where concerns had been escalated to a risk register, some concerns had remained on the registers for prolonged periods with no actions taken.

“Staff in most services could observe patients in all parts of the wards; we had concerns about the ability for staff to observe patients on two of the wards. The trust had not taken action to mitigate risks in these wards.

“Wards used parabolic mirrors where there were blind spots. Some wards had close circuit television cameras in communal areas.”

Specific findings relating to the Bronte Ward included:

“On Bronte and Blake ward, the bedroom doors were a standard “leaf and a half” acute hospital design which meant there were no observation panels.” [p.75]

“The service had high rates of bank and agency nurses and nursing assistants.

“The trust provided figures for bank and agency usage over the last 12 months. The highest usage was Elm ward, with 3934 shifts filled by bank or agency staff, Blake ward, with 3288 shifts filled by bank or agency staff, Bronte ward with 3169 shifts filled by bank or agency staff and Westleigh ward with 2943 shifts filled by bank or agency staff.” [p.78 – 79]

Further Notes to Editors

For further information please contact Sophie Henrys, Senior Marketing Coordinator at Farleys Solicitors on [email protected] or 0161 835 9513.

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