Yahoo News Inquest into death of 22-year-old woman who died at mental health unit adjourned while CPS investigate
An inquest into the death of a 22-year-old woman who died after staying at a Greater Manchester mental health unit has been adjourned to allow the Crown Prosecution Service (CPS) to investigate - leaving her family waiting for answers nearly two years after her death.
The inquest into Cerys Lupton-Jones’ death began at Manchester Coroner’s Court on Tuesday (May 9) and was adjourned under coroner Zak Golombek the following day.
Evidence has been referred to the CPS to allow them to investigate and decide whether any criminal charges need to be brought.
Cerys died following a stay of around six months in Park House, a mental health unit based at North Manchester General Hospital. The unit is operated by Greater Manchester Mental Health NHS Trust.
The 22-year-old was found ‘unconscious’ on Elm ward on the afternoon of May 13, 2022. She died five days later.
A pre-inquest review into her death in October heard Cerys was involved in a ‘ligature event’ the previous day, May 12, and another at around 2.30pm on May 13. She was then found unconscious after another incident involving a ligature half an hour later, at around 3pm.
The 3pm ‘ligature event’ proved fatal and Cerys died with her family and friends at her side on May 18, after it became clear she would not regain consciousness and her life support was turned off, her family told the M.E.N.
The pre-inquest review heard sheets of handwritten notes about the 15-minute observations of Cerys that were meant to take place from 1pm to 3pm on May 13 were ‘missing’.
On Tuesday (May 7) the inquest was told Cerys had returned to Elm Ward on May 6, 2022 after taking an overdose on April 28 that led to her being admitted to A&E and spending a night there. On her return to Park House she was initially admitted to Poplar Ward as her bed on Elm Ward was no longer available.
Two days after her return to Elm Ward on May 8 Cerys tied a ligature in one of the bathrooms. On that occasion staff were able to intervene.
Following the ligature incident Cerys was placed on one to one observation, meaning a member of staff was with her at all times.
Less than 48 hours her prescribed observations were however reduced to one every 15 minutes by consultant psychologist Dr Bhandary.
Just a matter of hours after Cerys’ prescribed observations were reduced there was another ligature incident. Cerys was taken to A&E with a head injury and was discharged later that evening at 10.30pm. She was placed on one-to-one observation by nursing staff at Park House but they were again reduced by Dr Bhandary.
Giving evidence on Tuesday, Dr Bhandary said he was not told about the ligature incident on May 10 when he came into work on May 11 and assumed Cerys was continuing on observations every 15 minutes.
He told the inquest he did not check Cerys’ progress notes that mentioned the incident as he expected that he would be told about any incidents by ward staff. He added that had he been told about the May 10 incident he would have kept Cerys on one to one observation.
Dr Papadopolus, who was working as a trainee psychiatrist under Dr Bhandary at Elm Ward at the time Cerys was there in May, then gave evidence.
He said he too was not made aware of the ligature incident on May 10 and that he next saw Cerys on May 13 for a ward round but did not notice any signs of ligature. He said it was his understanding there had not been any incidents since the last time he saw her.
The inquest then heard that the last thing Dr Bhandary asked Cerys to do following their meeting on May 10 was to write a letter detailing her feelings. Within the letter Cerys wrote she was in a ‘constant state of panic’, felt ‘constantly overwhelmed’ and that her panic was causing 90 per cent of her ligatures.
Dr Papadopolus said he read the letter at the start of his shift on May 13 and changed Cerys’ medication as a result. She was not put back on one-to-one observations.
