25 April 2024

Before HM Senior Coroner Joanne Kearsley
Rochdale Coroner’s Court, Newgate House, Rochdale OL16 1AT
8-25 April 2024

Charlie Millers, a 17 year old transgender boy, died following a ligature incident whilst a mental health patient on the Junction 17 ward, Prestwich Hospital in December 2020. Charlie was one of three young people to die in the CAMHS unit of the hospital in less than a year.

Today a jury concluded that there were multi-agency failings leading up to his death. They found that Charlie did not intend to end his own life.

Charlie was from Stretford in Manchester. He was a talented artist who loved Morris dancing, football and animals. His family describe him as ‘an amazing human’ with a ‘smile that affected and melted away a thousand hearts’, who made time for others regardless of how much he was struggling.

Charlie had experienced behavioural issues since primary school and mental ill health since the age of 11. He was diagnosed with ADHD and was believed by professionals to have autism. Charlie came out as a transgender boy when he was 12 years old. In Charlie's early teens, he experienced a number of issues which sadly led to a deterioration in his mental health which resulted in him beginning to self-harm.

At the time of his death, Charlie was receiving gender affirming healthcare and attending a gender clinic. Charlie experienced bullying at school as a result of his gender identity, which contributed to his poor mental health.

The inquest heard evidence from Dr Carmichael, the Director of Gender Identity Development Service (Gids) who said that Charlie was due to progress onto medical intervention treatment including hormone blockers. However, he would not have progressed onto a treatment plan unless his mental health and self-harming had stabilised. This would not have been communicated to Charlie whose ongoing gender dysphoria was a cause of significant distress.

Charlie was receiving support from Trafford Social Services and was on a Children in Need plan. However, due a to significant deterioration in his mental health, he was admitted under section to Junction 17 on three occasions in 2020, including after multiple self-harming incidents, in the months and weeks before his death. 

Charlie was allowed to leave the hospital on granted home leave which meant he would spend time at home, which was extremely important to Charlie and was a central part of his treatment plan.

Charlie was first admitted to Junction 17, a Child and Adolescent Mental Health (CAMHS) inpatient ward, in July 2020, following a serious overdose. Charlie’s mum gave evidence that the care he received on the ward was inconsistent and that he would often be taken off section or given home leave as a form of punishment for his behaviour.

Charlie was placed under section 2 of the Mental Health Act (for assessment) before being discharged from Junction 17 on 4 September 2020. Five days later, on 9 September, there was a serious self-harm incident involving an overdose. Charlie was detained again and returned back to Junction 17 only to be discharged again on 13 October 2020.

Charlie’s psychologist gave evidence that by this time his level of need and risk had increased, and that inpatient admission was identified as harmful for him, but there were limited options as to where he could go.

She said that professionals had formed ‘fixed views’ and there was a tension between social care, namely Trafford Borough Council who thought Charlie needed to be in hospital and hospital staff who thought he should be in the community.

Junction 17 staff were resistant to Charlie being re-admitted as they felt that they had done all they could for Charlie and that inpatient detention was no longer appropriate. The local authority disagreed and felt unable to manage Charlie’s risk in the community.

Professionals gave evidence that they felt there were no viable therapeutic alternatives to inpatient admission and that a bespoke package would take around 2-3 months to be progressed.

Charlie was admitted to the ward for the final time for six weeks from 20 October 2020, with occasional days of leave. Charlie’s treating psychiatrist told the jury that by the time of his third and final admission, Charlie was the most vulnerable child on the ward in terms of self-harming.

On 7 November there was a multi-agency meeting where it was recognised that Charlie’s level of risk had increased. Consideration was given to placing him on a secure unit. Charlie's CAMHS case manager told the jury that Charlie's was ligaturing in hospital as he could be almost certain that staff would find him.  

On 12 November 2020, Charlie was taken to A&E after a serious ligature attempt which led to him being resuscitated. Following Charlie's return to the ward, he was placed on increased observations and was to be monitored at least every 5 minutes with 1:1 support and a plan for continuous observations if his risk increased.

On Monday 30 November 2020, Charlie seriously self-harmed and was taken to North Manchester General A&E. He was returned to the ward two days later, after a night at home.

2 December 2020

At 7:45pm, Charlie returned to Junction 17. Staff were aware that return from home leave was a particular trigger for Charlie. As part of his ligature care plan because he was likely to self harm, he was placed on 1 in 5 minute observations.

Staff described the ward that night as ‘bouncing’, ‘visibly chaotic’ and ‘unorganised’. The ward manager was working a double shift that day due to staff shortages, as the planned nurse in charge for the night shift on December 2 could not return after being assaulted by a patient.

Charlie went on to tie at least four ligatures that night, each of which required the use of ligature cutters to remove. The fourth of these ligatures proved to be fatal.

The jury heard that documentation regarding Charlie’s observations had not been filled in correctly by the ward manager and staff members’ names were listed as having completed checks, when those checks had in fact been completed by others. Witnesses could not recall exactly who had done the checks but said they believed the checks would have taken place every five minutes as required. The relevant 1 in 5 observation document was never located and the nurse in charge's timeline had been "shredded."

A support worker on the ward gave evidence that she found Charlie ligatured in his room just after 8pm. She described the ligature as tight and that due to Charlie’s non-compliance, staff had to hold his arms in order for it to be cut off.

When asked, the ward manager stated she did not think it was necessary or appropriate to increase Charlie’s observations following the serious ligature incidents that occurred that night.

She gave evidence that Charlie would sometimes ligature 5 or 6 times on return from home leave. She described this as ‘his usual pattern’ and stated that even had the ligatures been tight, it was ‘a risk which we’d been managing’ and that putting him on 1:1 observations could also increase his risk.

The member of staff conducting the observations on Charlie discovered him ligatured for the fourth and final time in his room at 10:30pm. He was taken to Salford Royal Hospital and sadly died five days later on 7 December 2020.

The jury concluded that Charlie did not intend to end his own life. They also found that:

• Trafford Children’s Services did not engage with the mental health services and failed to provide support for Charlie’s mum and siblings. This resulted in Charlie being readmitted to Junction 17.
• Charlie should have been subject to a Child Protection plan.
• Charlie should have had an assessment in addition to his CAMHS plan to consider what he needed from a care perspective, to support him in the community.
• Record keeping on Pegasus ward was inconsistent and incomplete for the evening of 2 December.
• The decision not to place Charlie on 1:1 observations due to his decreased haemoglobin levels [following a previous self harm incident] probably contributed to his death.

Sam Millers, Charlie’s mother said: “As a family, we are pleased that the jury found multiple failings across multiple agencies involved in Charlie's care. As the Coroner said at the end, this is the first independent investigation into Charlie's death which has come way too late. 

There were gaps in the evidence in that we did not have statements from key witnesses and some of the key witnesses were not interviewed until approximately two years after Charlie's death. 

In their findings, the Jury relied on the police investigation. The police in turn relied on the GMMH internal review, which was not independent and was signed off by Charlie's Consultant Psychiatrist himself and the CAMHS operations manager who failed to ensure there was a robust system for monitoring observations after the death of Rowan Thompson.

We will never know the truth of what happened to Charlie because the accounts are so inconsistent and there is not documentary evidence that five minute observations were properly completed. 

We are deeply concerned that GMMH still has not learned and does not have a more robust process in place for ensuring that observations are carried out according to policy.”

Kelly Darlington of Farleys Solicitors and Ciara Bartlam of Garden Court North, said: “17-year-old Charlie was let down by the health and social care system when he needed it the most. The Jury's findings in respect of the shortcomings in the care and support both Charlie and his family should have received by Trafford Borough Council when he was at his most vulnerable are welcomed. 

There are clear lessons that GMMH need to learn in respect of the adequacy and quality of patient observations to protect the safety and lives of other patients.

The Coroner has identified serious concerns in respect of the quality of investigations and the effectiveness of investigative learning in mental health deaths.

Charlie's death has highlighted the urgent need for independent oversight of mental health related deaths which currently does not exist and the family are pleased that the Coroner intends to write to the Secretary of State for Health and Social Care in this regard.”

Jodie Anderson, senior caseworker at INQUEST, said: “Every child should have access to the care and support they require to keep them safe. Being autistic and transgender meant that Charlie was even more vulnerable, marginalized and stigmatized and yet he was failed across the board, with fatal consequences. 

The attitudes of many professionals were as dismissive of Charlie in life as they were in death. His clear cries for help and threats to end his life were not taken seriously. 

At the inquest many staff who were entrusted with Charlie’s care could not even answer basic questions about what happened on the night in question. It’s disappointing that the jury conclusions did not reflect this.

Public services locally and nationally must now take responsibility and action to ensure no other child dies a preventable death like Charlie.”

ENDS

NOTES TO EDITORS

For further information, interview requests and to note your interest, please contact Lucy McKay on 020 7263 1111 or [email protected] 

Photos of Charlie for media use: Photo 1, Photo 2

The family are represented by INQUEST Lawyers Group members Kelly Darlington and Alice Wood of Farleys Solicitors, and Ciara Bartlam of Garden Court North chambers. They are supported by INQUEST senior caseworker, Jodie Anderson.

Other Interested persons represented are the Greater Manchester Mental Health Trust (‘GMMH’) (who run Junction 17), Trafford Borough Council (Children’s Services), Northern Care Alliance NHS Group, NHS England, Manchester University NHS Foundation Trust, Care Quality Commission, Pennine Care NHS Foundation Trust.

Journalists should refer to the Samaritans Media Guidelines for reporting suicide and self-harm and guidance for reporting on inquests.

Other deaths on the unit:

• Rowan Thompson, 18, died on 3 October 2020 whilst an inpatient at the Gardener Unit, a medium secure adolescent mental health unit in Prestwich Hospital. Rowan was non-binary. An inquest in December 2022 found that their death was contributed to by neglect due to the failure to communicate the findings of blood tests. Media release
• Ania Sohail, 21, died in June 2021 whilst at Junction 17 in Prestwich Hospital. The inquest concluded that her death was contributed to by ineffective policies and various issues. See media coverage and the Prevention of Future Deaths report. 

Independent Review into Greater Manchester Mental Health NHS Trust 

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 quality of care within the Trust. The review concluded that within GMMH, there was a ‘culture that valued operational performance above clinical quality’.

At the inquest 'Professor Oliver Shanley OBE, Chair of the review, gave evidence that:

• Staff on inpatient CAMHS units said they didn’t always feel sufficiently experienced to meet the needs of children.
• There was a issue of high turnover of staff and retention.
• There was no formal system in process for observation audit and when this was raised, the Risk and Assurance Group assumed the observation audits were happening when in fact they were not. 
• In 2021, audits were completed 7/28 times, in 2022 audits were completed 25/52 times and 2023 were completed 9/36 times. 
• The BBC Panorama documentary raised the issue of observations not being done correctly or being falsely accounted for. There was an opportunity for learning 2-3 years ago, which the organisation hadn’t implemented.