'The outcome of the 2020 investigation is that the ward was adequately staffed, but you didn’t speak to all of the staff?', the coroner questioned
Greater Manchester Mental Health Trust's investigation into the death of Charlie Millers has been described as 'lacking' after bosses failed to speak to all staff members working on the ward at the time when the teenager was fatally injured there.
The audit programme followed concerns in October 2020 that those regular checks, where patients are observed a set number of times an hour in accordance with their condition, were not accurate or simply not being done. But it was later found that the 'there was no evidence' some of the audits themselves were ever done.Charlie died from a hypoxic brain injury after being found completely unconscious with injuries caused by a ligature.
But the coroner added that, during a review of GMMH failings which was published earlier this year, ‘there wasn’t the evidence to show that those audits were being done’. Ms Kearsley asked if, given these gaps, Ms Clarke thought the ‘investigation was lacking somewhat’. “If they’ve not spoken to every member of staff, I’d agree, that would be correct,” Ms Clarke replied, adding that she 'didn't carry out the investigation' herself.
Staff members’ names were additionally listed as having done the checks, when those checks had in fact been completed by others.
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