The inquest into the death of Rowan Thompson concluded yesterday (31 October 2022), with the jury finding that Rowan died of Cardiac Arrythmia due to Severe Hypokalaemia of unknown cause, contributed to by neglect due to the failure to communicate the findings of blood tests.
The inquest was heard over six days at North Manchester Coroner’s Court in front of HM Senior Coroner Ms Joanne Kearsley, sitting with a jury.
Rowan died on 3 October 2020 whilst an inpatient at the Gardener Unit, a medium secure adolescent mental health unit in Prestwich run by Greater Manchester Mental Health NHS Foundation Trust (GMMH). Rowan, who identified as non-binary, was 18 at the time of their death.
On 2 October 2020, blood tests were requested by Rowan’s psychiatrist to establish if there was a medical reason for Rowan’s noticeable weight loss. The jury found that the blood tests showed evidence of Severe Hypokalaemia but that the results were not communicated to the medical team and as a result life-saving treatment was not commenced.
Toxicologist Dr Stephen Morley told the inquest that Rowan’s potassium levels had been “life threatening” and that a timely admission to hospital could have saved their life. Rowan’s psychiatrist, Dr Malik, said he would have sent Rowan to A&E straight away had he received the results at the right time.
The blood samples were processed by Salford Royal Hospital at 13:10 on 2 October 2020, showing a potassium level of 2.3mmols. A further test was taken at 13:37 which confirmed the same result. The Royal College of Pathology states that a result of potassium levels below 2.5mmols must be verbally communicated within 2 hours of findings.
Numerous attempts were made by Salford Royal Hospital to communicate the results to the Gardener Unit between 13:40 and 16:58, all of which were unsuccessful due to phone numbers no longer being in service and email issues. The jury found that there was a failure by Northern Care Alliance (NCA), who are responsible for Salford Royal Hospital, to communicate the blood results and this probably caused or contributed to Rowan’s death.
The jury also found numerous failings on behalf of GMMH, including that the failure to provide the correct contact details probably caused or contributed to Rowan’s death.
Rowan was on 1:15 minute observations. The jury found that 5 out of 8 members of staff on the ward falsified observation records. On 3 October 2020 between 07:00 and 12:45, 9 out of 24 quarterly observations were carried out. 24 out of 24 observations were signed off. However, the Senior Coroner directed the jury that there was no evidence to indicate that any such failure in this regard caused or contributed to Rowan’s death.
At 12:54 on 3 October 2020, a staff member found Rowan on their bed appearing to be having a seizure. CPR was commenced at 12:57 and an oxygen mask was placed on Rowan, though the jury recorded that this appeared to be defective as it didn’t inflate. A call to emergency services was made at 13:03 and the paramedics arrived at Prestwich Hospital at 13:06, but were not able to arrive at the scene until 13:25. At this point the paramedics took over the care of Rowan and left by ambulance at 13:56. The ambulance arrived at North Manchester General Hospital at 14:06 and sadly Rowan was pronounced dead at 14:25.
A number of failings were admitted by GMMH prior to the inquest:-
There was a failure by staff on the morning rota to perform observations on Rowan on 3 October 2020 in line with his care plan.
Staff completed observation documentation detailing observations that had not in fact been undertaken on 3 October 2020.
There was a failure by staff to contemporaneously sign the observation sheet verifying the observations that were undertaken on 3 October 2020.
Staff signed the observation sheet indicating observations had been undertaken on Rowan when they themselves had not undertaken those observations but signed on behalf of another member of staff.
A failure by the Trust to have noted the correct telephone number of the Gardener Unit on the Trust’s internet.
A failure by the Trust in providing the caller from Salford Royal Hospitals with an email address that was in fact an internal email address to be used to retrieve voice mail messages rather than to receive emails.
In addition, a number of failings were also admitted by Northern Care Alliance:-
There was a failure by the Trust to continue attempts to contact the Gardener Unit to communicate the potassium result after 16:58hrs on 2 October 2020.
There was a failure by the Trust to ensure the potassium result remained on the DEPHO list for outstanding abnormal results, to ensure it was visible to laboratory staff that it was still outstanding and required escalation. The blood test results were removed from the DEPHO list at 14:42hrs on 2 October 2020, after which the Trust continued to attempt telephone contact with the Gardener Unit until this ceased after the final attempted call at 16:58hrs.
There was a failure by the Trust to have a contingency within its escalation policy making staff aware how to escalate issues with the communication of blood test results in the event of an inability to contact the Gardener Unit through agreed methods.
Following the jury’s findings, the Senior Coroner confirmed that she would be raising three issues in a Prevention of Future Deaths report, including: the ability for paramedics to navigate the Prestwich Site; whether blood test forms had been changed to include the correct contact details between GMMH and NCA; and the lack of CCTV being checked for observations made by staff at the Prestwich Site.
Rowan’s father, Marc Thompson, said:
“I’m pleased that through the Coroner’s investigation we have identified a cause of death which brings me some solace, but tempered by the knowledge that Rowan’s death was totally avoidable. Culminating in the Jury concluding there was a ‘gross failure to provide basic medical care’ (neglect).
“Rowan was a brilliant and unique individual and not a day goes by that I don’t think about him.”
Lucy McKay, spokesperson for the charity INQUEST, said:
“Rowan was a young person with serious mental and physical ill health. They were in the care of hospitals which should have kept them safe. Yet dysfunctional care and communication between medical professionals, evidenced at this inquest, was shambolic to the point of neglect.
“Rowan was one of three young people to die in the care of Prestwich Hospital, and one of many more to experience harm in the care of Greater Manchester Mental Health NHS Foundation Trust. The issues identified here are systemic at both a local and national level.
“INQUEST are calling for an urgent statutory public inquiry into deaths and serious incidents in metal health settings, to challenge the failing mental health and regulatory systems which continue to enable preventable deaths.”