Two brothers with unrelated health issues tragically died within five months of each other due to mistakes, failings or neglect by medics from the same NHS trust.
Matthew Copestick, 21, who had autism and alcohol problems collapsed and died in his shower four days after being sent home from hospital when 'poor communication' by health staff caused him to be wrongly assessed as ''medically fit.''
Five months later his older brother Sam, 24, a former university student suffering from severe paranoid schizophrenia, also died.
He took his own life after he vanished whilst on escorted leave with a nursing assistant from a psychiatric unit.
It emerged their mother had complained about a lack of communication between herself and NHS staff but her concerns were not acted upon.
Today Pennine Care NHS Trust in Oldham, Greater Manchester was criticised by Sam and Matthew's parents after inquests into their deaths in January and May 2019 condemned the health body and other agencies for mistakes made over their medical treatment.
A jury last Friday concluded Sam's death was contributed to by neglect whilst in January a coroner cited failures over communication and planning as being a factor in Matthew's death.
In a statement the brothers' mother Helen McHale said: “Looking after people who are mentally ill is challenging, requires care, patience, skill, and sometimes things go wrong. 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."
Lee Copestick, Sam’s father, said: “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.”
In a joint statement about Matthew's death the parents added: ''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 and it haunts us now.''
Football fan Matthew, from Rochdale described as a ''friendly, funny and kind hearted man'' was said to have a high level of care needs and had developed a life threatening alcohol problem due to his Aspergers.
On January 4 2019, he was found unwell at home by his carers and was taken to Fairfield Hospital A&E unit in Bury where a triage nurse believed he needed alcohol detoxification at a specialist treatment centre.
But due to ''poor communication and a lack of understanding'' between staff about his autism, he was not admitted as an inpatient and was instead discharged.
Matthew was said to have had a “meltdown” before he left hospital and died at his home four days later from complications caused by his alcohol use.
A post-mortem found that Matt’s liver was significantly enlarged although toxicology tests showed that at the time of his death there was a very low level of alcohol in his system.
Sam described as ''highly intelligent and good at every sport'' had been treated at Prospect Place unit in Rochdale since 2017 after his mental health deteriorated in his teens.
He had previously thrown himself under a train and his condition worsened after Matthew's death.
Sam’s care plan allowed for him to take escorted leave if accompanied by two members of staff, one of whom had to be male.
But in May 2019 he went out with only one member of staff, a female nursing assistant who had no phone with her.
Sam ran off whilst they were at the shops and was discovered a mile away. He was taken to the Royal Oldham Hospital but died three days later.
During the course of Sam's inquest, the Trust apologised to the family and accepted numerous failures including an absence of a risk management plan, failure to liaise with Sam’s mother, despite her raising concerns about his condition and the lack of staff looking after him whilst on the escorted visit.
The inquest also heard in 2018, Sam’s mother issued a complaint about the care Sam was receiving at the unit saying she believed medical staff were consistently 'under-estimating the risk' to her son.
Her complaint was investigated and recommendations were made for improvements but none would put into effect. The jury concluded Sam should never have been allowed out on leave.
Ruth Bundey from Harrison Bundey Solicitors, who represent the family, said: “It is beyond belief that senior Pennine staff ignored crucially informative and courteous emails, as well as calls, from Sam’s mother Helen, revealing her son’s increasing distress that if he went out on leave he would be killed.
''This followed two sets of admissions in the previous year that the Trust had not sufficiently listened to the family’s experiences. This devastating lack of respect ultimately led to Sam’s death.”
Fellow family lawyer Emily Comer added: “Matt’s family have fought tirelessly throughout this incredibly difficult process to gain answers from the parties involved. With the coroner’s conclusions, we hope that lessons will be learnt across organisations to avoid such avoidable tragedy in the future”.
Lucy McKay, spokesperson for the charity INQUEST, said: “It is clear that Sam’s family fought for him to receive the care he needed, right to the end. Despite their tireless efforts, Pennine Care NHS Foundation Trust neglected both Sam and his family.
''At INQUEST we see that mental health services all too often overlook the invaluable insights of families and fail to effectively manage risk and plan for patients taking leave. We must now see action, not just in this area, but nationally to ensure these repeated failures do not continue.”
Selen Cavcav, Senior Caseworker at INQUEST said: “The failures in this case would not have come to light without the family’s tenacity and their drive to prevent other young people like Matthew dying.
''There is a systemic issue in relation to the delivery of life saving services for vulnerable people with autism. One size does not fit all. Ignorance, lack of training and lack of a person centred approach continues to end in so many deaths. Failures identified in this case must be addressed at a national level.”
Clare Parker, executive director of nursing, healthcare professionals & quality governance at Pennine Care NHS Foundation Trust, 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.”
She added: "We would again like to offer our deepest apologies to Sam’s family. Our thoughts go out to them and all those who knew Sam.
"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.”
