Inquest resumes into death of 27-year-old Charlotte Sophia Parry who died whilst an inpatient at the GMMH Laureate Psychiatric Wing of Wythenshawe Hospital.
Before HM Area Coroner Paul Appleton
Manchester Coroner’s Court
Opens Monday 31st March 2025 (with evidence commencing on Tuesday 1st April 2025)
Scheduled for 2 weeks
Charlotte was 27 years old when she died from injuries sustained whilst a mental health patient on the Bronte Ward, Laureate House, in the grounds of Wythenshawe Hospital on 6th February 2022. An inquest will now resume to examine the circumstances and care provided by Greater Manchester Mental Health NHS Foundation Trust.
The Trust has received significant local and national attention following a BBC Panorama investigation of the Edenfield Centre in Prestwich, run by GMMH, and the Independent Report commissioned by NHS England in 2024 which looked at various areas of concern within the Trust.
Charlotte was a twin born just one minute after her sister with whom she shared an incredible bond. From an early age it was clear Charlotte had a passion for helping others and, at the age of 9 years old, was instrumental in helping her Grandad to recover from a devastating stroke. Through Charlotte’s love, care, and compassion for others, her grandad was able to walk again. Unbeknown to her parents, at this young age Charlotte had already chosen her career path and went on to study Occupational Therapy at Liverpool University.
Charlotte loved life. She was a people person and loved to travel. Most of all Charlotte loved her family and her nephew was the light of her life.
Sadly, Charlotte struggled with her mental health and had sought input and help from professionals over a number of years. Following a significant deterioration in her mental health, Charlotte was transferred to Bronte Ward under S3 MHA 1983 on 19th October 2021. The intended plan had been for her to be transferred to a specialist hospital for individuals with a diagnosis of personality disorder. Assessments and funding were being sought for her but sadly she died prior to any transfer taking place.
In the months following her admission to the Bronte Ward, Charlotte attempted to take her own life on multiple occasions. Over the course of 7 days in the November period, there were five documented incidents of Charlotte tying a ligature. Charlotte’s ligature attempts continued right up to her death. On 30th January 2022, Charlotte was found by a nursing assistant with a ligature suspended from a chest of drawers. The drawers had previously been removed following a ligature attempt using bed sheets which were wedged within her chest of drawers less than a month earlier, but were returned shortly before Charlotte’s death.
Charlotte’s family have serious concerns about the care she received whilst an inpatient on the Bronte Ward.
The Article 2 inquest will be held before a jury and will consider a number of issues, including the care and treatment provided to Charlotte by GMMH and whether healthcare staff failed to take reasonable steps to prevent her death. This will include whether ligature risks were managed appropriately.
In January 2024, an Independent Review of GMMH commissioned by NHS England was published. The investigation and its findings looked at various areas of concern regarding the quality of care within the Trust, including in relation to the management of ligature risks for in-patients. That report noted that, in 2022, 26% of all suicides involving ligatures on inpatient wards in the UK took place in GMMH, and that GMMH accounted for approximately 11% to 15% of all inpatient deaths in England. Written evidence will be heard at Charlotte’s inquest from Professor Oliver Shanley OBE, Chair of the review.
The CQC has also repeatedly raised concerns in its inspections of GMMH acute wards. On 20th June 2024, the CQC served section 29A warning notice on the Trust for “lack of effective governance systems, ligature risks and fire safety concerns, medicines not managed safely, ward security systems not consistently keeping people safe, infection prevention and control risks and staff not up to date with mandatory training”. The CQC can serve a Warning Notice when concerns are identified across either the whole or part of an NHS trust, and there is a need for significant improvements in the quality of health care. This includes concerns that are probably systematic and affect the entire system or service, rather than being an isolated matter, and/or result in the risk of harm or actual harm.
The family are represented by Kelly Darlington of Farleys Solicitors, and Lily Lewis of Garden Court North Chambers.
Other interested persons represented are the Greater Manchester Mental Health Trust (‘GMMH’) who are the service provider for Laureate House, Wythenshawe Hospital.
