Brothers died weeks apart due to NHS failings
TWO brothers who suffered with different mental health conditions died months apart after ‘poor communication’ and hospital failings at the same NHS trust.
Sam Copestick, 24, who had paranoid schizophrenia, died of selfinflicted injuries after running away from a support worker while out on a walk from a specialist care unit in Wardle, Rochdale.
Just five months earlier, his brother, Matthew, 21, died after collapsing in the shower four days after being discharged from Fairfield General Hospital in Bury.
Separate inquests into the deaths highlighted problems within the Pennine Care NHS Trust which led to the tragic incidents.
Speaking after the conclusion of Sam’s inquest, his heartbroken mum, Helen McHale, said she had ‘little confidence’ that the health services would improve.
“Looking after people who are mentally ill is challenging, requires care, patience, skill, and sometimes things go wrong,” she said. “The continued nature of these failings, however, is far deeper and longerlasting than simple mistakes. Trying to get Sam’s distress and risk accepted was a constant battle.”
A four-day inquest at Rochdale Coroners Court heard that Sam should have been accompanied by two members of staff when he went on a walk from Birch Hill Hospital’s Prospect Place unit in Wardle on May 20, 2019. Instead there was one, and she left without a phone.
Sam ran from her and later died as a result of self-inflicted injuries.
An inquest jury heard that mum Helen had made a complaint about the care he had received at the unit in 2018 which was investigated, with recommendations for improvement made. But the inquest heard that they were not put into effect.
In its conclusion, the jury found that ‘neglect’ contributed to Sam’s
death and that he should not have been allowed to leave the unit following concerns raised by his mum at recent care planning meeting.
The jury identified a number of other failings which contributed to Sam’s death, including:
Failure to implement lessons of previous complaints by Sam’s parents regarding under-estimation of risk.
Failure to give adequate weight to Sam’s mother’s concerns regarding his mental health following his brother’s death.
Failure to check the leave form which instructed two staff members to escort Sam.
Failures around planning and risk assessment prior to the leave.
Senior coroner for Manchester North, Joanne Kearsley, presiding over the hearing, said she was ‘not minded’ to make a ‘Regulation 28’ ruling – which would involve preparing a report to prevent other deaths.
Following the inquest, Clare Parker, director of quality, nursing and healthcare professionals at Pennine Care NHS Foundation Trust, said: “We are truly sorry about the failings and put an improvement plan in place straight after our investigation to try and ensure this never happens again. This has included investment into a dedicated service manager and also a head of quality post.”
Sam’s brother, Matthew, died
from complications caused by alcohol dependency just days after ‘poor communication’ meant he missed out on an emergency detox. The 21-year-old had a history of drug and alcohol abuse and collapsed in the shower on January 8, 2019. Just four days earlier, he had been taken to A&E at Fairfield General Hospital after feeling unwell, an inquest heard.
A triage nurse believed he needed treatment for alcohol detoxification at specialist treatment centre the Chapman Barker unit but an inquest at Rochdale Coroners Court heard Matthew, who had autism, was discharged as medically fit instead. His father described him having a ‘meltdown’ before he left hospital.
“Due to poor communication between staff and a lack of understanding by the alcohol liaison nurse as to the requirements for an emergency inpatient admission to the Chapman Barker unit Matthew was not admitted for an inpatient alcohol detoxification,” Coroner Kearsley ruled.
The inquest into Matthew’s death heard of a number of issues surrounding his treatment, including a delay in referring him for specialist care and communication problems among several agencies involved in looking after him. Ms Parker said: “We accept the conclusion of the coroner and recognise that there are lessons to be learnt.”