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 self-inflicted injuries after running away from a support worker while out on a walk from a specialist care unit in Wardle.
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.
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Separate inquests into the deaths of both men 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 told the Manchester Evening News.
"The continued nature of these failings, however, is far deeper and longer-lasting than simple mistakes. Trying to get Sam’s distress and risk accepted was a constant battle.
"I know from talking to other carers and hearing other stories that these mistakes are repeated elsewhere. I truly hope these findings improve things for them.
"Given the continued inability to deliver some fairly simple changes, I have little confidence they will, but want to help in any way I can.
"I cannot thank enough the jury, coroner, family, friends, colleagues, our solicitor, and (support organisation) INQUEST, for all who played a crucial role in getting to this point. It would not have been possible without them.”
Sam's dad, Lee Copestick, added: "In the last two-and-a-half years of Sam’s life I slept a little easier believing he was in a safe place.
"Since Sam’s passing, I have been angry and deeply sad realising that was not the case.
"These feelings remain now that the court too has concluded that Sam’s death was preventable.
"I hope that Pennine Care go away and make big changes to ensure that no one ever has to endure what we have been through.”
'Neglect' contributed to Sam's death
A four-day inquest held 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 had left without a phone.
Sam ran from her and later died as a result of self-inflicted injuries.
An inquest jury heard that Sam's 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, including failures to complete and countersign the required risk assessment plan, insufficient information on the leave form, and inadequate signing of the leave description sheet.
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.
She said from the evidence: "It is clear the health trust has taken many steps following Sam's death to rectify many issues raised during the investigation."
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.”
Second tragedy to hit the family
It was the second time in a year that the Copestick family had dealt with tragedy.
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, on January 4, he had been taken to A&E at Fairfield General Hospital after falling unwell, an inquest heard.
A triage nurse believed he need treatment for alcohol detoxification at specialist treatment centre the Chapman Barker unit but an inquest at Rochdale Coroner's Court heard Matthew, who had autism, was discharged as medically fit instead.
Sam's brother was left distressed by the news he wouldn't be admitted to the Chapman Barker Unit - 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," senior coroner Joanne 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.
In a joint statement released following the death of their first child, parents Helen and Lee said: “Having sat through all the evidence it remains clear to us that Matthew did not need to die.
"It is clear that Matt was let down and that better communication, an understanding of how Matt's autism impacted on him, and listening to us more, would have resulted in a different outcome.
"Days before his death Matt said ‘Mum I want my detox before I die’. This had a powerful impact then, but it haunts us now."
Care agencies involved in looking after Matthew, including Rochdale council and the Turning Point drug and alcohol service, promised to make changes to their systems after his death and follow the coroners recommendations.
Ms Parker, who was executive director of nursing, healthcare professionals & quality governance at Pennine Care NHS Foundation Trust at the time, said: “We offer our deepest sympathies to Matthew's family for the loss of their much loved son.
"We accept the conclusion of the coroner and recognise that there are lessons to be learnt.
"We are working on improving communication between teams to ensure all alcohol referral pathways for patients attending A&E are understood. As a trust, patient safety is a priority and we are sorry that on this occasion the referral did not happen.”
