The inquest into the death of Charlotte Parry concluded on Friday 11 April 2025, with the jury finding that Charlotte died by suicide contributed to by neglect.
The Inquest was heard across 10 days at Manchester Coroners Court in front of HM Area Coroner Paul Appleton.
Background to Inquest
Charlotte was an inpatient on the Bronte Ward between October 2021 and January 2022. Charlotte had a history of self-harm and suicide attempts, having been diagnosed with EUPD, OCD and Generalised Anxiety disorder.
Charlotte was found on 30th January 2022 at 19:47, having ligatured in her room on the Bronte Ward of Wythenshawe Hospital, having used an hessian bag for life and a chest of drawers. Prior to this, Charlotte had already made multiple ligature attempts, including using a tote bag and twice using her drawers in December 2021.
The drawers had been removed from Charlotte’s room in December 2021, however a decision had been made to return them to Charlotte on the 20th January 2022.
Charlotte had also been on 1:15 observations since the start of her stay, meaning that she was due to be observed every 15 minutes. However, on 28th January 2025, a decision was made to reduce Charlotte’s observation levels to “general”, meaning that observations would only be once an hour. Charlotte herself had raised concerns about this reduction in observations.
Assessments had been made to move Charlotte to a specialist therapeutic placement, however the Inquest revealed that no evidence of an application for this funding could be found, despite Charlotte having been accepted to a specialist placement in December 2021. Charlotte sadly died following the ligature attempt due to brain damage and compression of the neck on 6th February 2022.
The Inquest heard evidence from a range of witnesses, including a statement from the family, evidence of those who were present at the time of the incident, and senior management of the Trust. A number of admissions were made by the Trust, although these were not admitted having contributed to Charlotte’s death. The key admissions were:
- There should have been a documented individualised risk assessment in relation to the hessian bag.
- The risk management plan should have been adequately updated.
- There should have documented discussions as to the decision to return the chest of drawers to Charlotte.
- The Chest of Drawers should have been identified as a ligature risk at earlier Risk Assessment Audits.
- All furniture should have been fixed/non-moveable.
- Specialist placement funding should have been applied for.
- Observation sheets for January 2022 should have been located by the Trust.
- Staff should have had clarity as to Charlotte’s observation levels.
- Staff should not have been on their phones.
Decision of the Jury
The Jury made several findings, particularly that a change in observation levels, the clinician’s risk management of Charlotte’s chest of drawers, and allowing Charlotte to have access to the bag, contributed to or caused her death.
It was found that the environment on the Bronte Ward possibly contributed to Charlotte’s death, and that failures of staff to properly arrange for Charlotte to move to a specialist therapeutic placement contributed to or caused her death.
The Jury and Coroner also raised key concerns with the governance and oversight of the Trust, reflecting the CQC and NHS England findings of recent years. It was found that systems in the Trust for managing ligature risk were inadequate, and that there were significant failures in the Trust at a senior level.
The Family are represented by Head of Inquests at Farleys Solicitors Kelly Darlington. Lily Lewis of Garden Court North Chambers was instructed to represent the family.
Kelly Darlington commented,
“the Jury’s conclusion that Charlotte’s death was contributed to by neglect is welcomed by the family. Upon reaching this conclusion the Jury felt that the significant failings and concerning features in her care were as a result of “incompetence” at a senior leadership level within GMMH. This follows the Independent Review commissioned by NHS England into practices at GMMH which highlighted many of these issues. The Trust now need to act and improve their systems that are failing to protect its patients.”
The Family of Charlotte have made the following statement,
“We as a family are absolutely devastated. For the jury to conclude neglect by GMMH contributed to Charlotte’s tragic death makes this even more unbearable. To date, we have not received any sort of apology for their significant and systematic failures including numerous critical findings in relation to Charlotte’s care.
“We would like to thank HM Coroner Mr Appleton, the Jury and the teams at Farleys Solicitors and Garden Court North Chambers for their professionalism and kindness. We are pleased that Prof. Shanley and CQC are closely monitoring GMMH’s practices and hope that changes continue to be made to protect other patients within their care.
“We continue to navigate life without our beautiful Charlotte.”
The Family concluded the Inquest with a video of Charlotte, and asked that everyone remembers Charlotte how they knew her; a passionate, kind and caring young woman who loved her family and worked diligently helping others.
