Hospital neglect contributed to vulnerable woman’s death, coroner says

Warning: The following article contains details about suicide that some may find distressing

Cerys Lupton-Jones stands between two doors.

One of the doors leads to a side room in the Manchester mental health unit where he is a patient. The other one opens to the toilet.

The 22-year-old man had tried to take his own life just 20 minutes earlier but no staff were visible on CCTV footage inside the unit.

He walks back and forth hesitantly for about 30 seconds. He then goes into the toilet and closes the door.

The next time he is seen on footage, doctors and nurses struggle to resuscitate him.

Cerys died five days later, on May 18, 2022.

A coroner concluded that some of the care given to Cerys at Park House, run by Greater Manchester Mental Health NHS Foundation Trust, was “a mess”.

Staff had to check on him every 15 minutes.

However, the last sighting recorded at 15:00 was refuted by saying that he was seen in a corridor. CCTV shows that at that point Cerys was in the toilet where she could have fatally harmed herself.

A staff member who was supposed to be looking after him has now admitted to falsifying those records.

Manchester coroner Zak Golombeck said if someone had stayed with him after his earlier attempt to take his life, what happened next might never have happened. He said neglect likely contributed to her death.

Campaigners are calling for an investigation into the number of deaths at the mental health trust and believe services are in crisis.

Greater Manchester Mental Health Trust said: “He failed him that day and we are deeply sorry we did not do more.”

Cerys’ parents, Rebecca Lupton and Dave Jones, describe their daughter as a loving young woman who would do anything for her friends. She was studying to be a nurse and was months away from receiving her degree when a job was arranged.

He was autistic and had also struggled with his mental health since his youth.

Her family, who live miles away in Sussex, say the pandemic and a reduction in community mental health support has made Cerys’ problems worse.

The inquest was told Cerys tried to take her life by spending time in A&E in the days leading up to her death.

He was then admitted back to Park House and given one-on-one observations for a short time. It then had to be checked on by staff every 15 minutes.

During the investigation, it was learned that on May 13, 2022, at around 14:35, Cerys was found in the toilet by Mohammed Rafiq, a health support worker who was assigned to check on her. Cerys had tried to hang herself.

Mr Rafiq and the duty nurse Thaiba Talib intervened.

But the inquest heard the 15-minute observations were not increased and staff did not speak to him properly.

The nurse told the inquest she did not believe Cerys intended to seriously harm herself.

He told the coroner that he chose not to increase observations on Cerys because he did not want her to feel punished because she did not like being under observation.

When asked by the coroner whether he should have gone with Cerys to her room after the incident to check she was safe, Ms Talib said: “In retrospect, yes.”

It was explained in court minute by minute that the cameras inside the unit were damaged.

It showed Cerys entering the ward garden at 14:42. The observation record, which stated that he was in his bedroom at 14:45, was described by the coroner as “not accurate”.

At 14:54 Cerys entered another toilet on the ward and closed the door.

However, Mr Rafiq told the coroner that he remembered seeing Cerys at 2.57pm. He wrote in his observation notes that he saw her “in the corridor with a dull face” at 15:00. Then he went on break. In reality, Cerys was still in the toilet.

The coroner told Mr Rafiq that his memories were inaccurate and that he had “falsified” observation records. Mr Rafiq replied: “I’m afraid so.”

Mr Rafiq said other staff showed him how to record observations every 15 minutes, even though he had not done so at the time. “This is how they did it, this is how I did it,” he told the court.

At 15:00, a new support officer took over the observations. There was no verbal handover and, according to Mr Rafiq’s notes, Cerys had just been seen.

CCTV shows the new support worker checking on other patients. He called Cerys at 15:15.

He could be seen becoming increasingly desperate as he explored the common areas and ran down the corridor.

At 15:19, he tried to open the toilet door using the master key. He found Cerys inside and immediately raised the alarm.

At this point it had been 25 minutes since Cerys had gone to the bathroom. He died in hospital five days later on May 18.

The coroner said Ms Talib had grossly failed to provide “basic medical care to a dependent person”.

He also discovered that there was a culture of falsifying records in the ward.

The coroner said it was not clear what Cerys’ intentions were. The narrative noted in its conclusion that negligence contributed to his death.

“I knew it was bad but listening to the evidence showed just how bad the care was,” Cerys’s mother Rebecca told the BBC.

Her father, Dave, says when Cerys was cut and hospitalized in early 2022, they believed it would keep her safe and help her recover. “It actually made everything worse,” he says. “It was the wrong environment.”

Outside court after the coroner delivered his verdict, Rebecca said: “Cerys was a wonderful, wonderful young man. We think she would be here today if she had been looked after better by Manchester Mental Health Trust.”

Dave noted that it was difficult to put the disbelief and anger into words. “We need more funding, more staff, better training and much better supervision for mental health services.”

Immy Swithern was ill at the same time as Cerys. They became close friends. He says they try to make the best of a bad situation and will talk all day.

He also claims some staff are not doing their regular 15-minute security checks, so they are trying to look out for each other.

“I was there to get better, and I was there to get help with that,” he says. “Instead, I was constantly checking on people. I think it was the most fear I’ve ever felt in that ward.”

Park House’s mental health unit has since closed. It was replaced by a new £105.9 million hospital in November 2024.

The NHS trust said it had “significantly improved” care and was grateful to the coroner for “recognising the work done to prevent something like this happening again”.

But campaigners claim mental health services in Manchester are in crisis.

Responding to Tuesday’s inquest decision, the Holistic, Accessible and Rights-based Mental Health Communities (CHARM) group said: “It is devastating to hear that yet another young person has lost their life as a result of neglect and inadequate care.”

The group said it would meet Greater Manchester Mayor Andy Burnham this week to call for a legal inquiry into the deaths and the financial crisis in the city’s mental health services.

In October 2022, five months after Cery’s death, an undercover BBC panorama program exposed bullying and mistreatment of patients at the medium-security Edenfield centre, also run by GMMH.

As a result, an independent review was commissioned by the NHS and published in 2024.

He found a “closed culture” at GMMH. It has also raised concerns about the number of deaths resulting from ligatures.

In 2022, 19 people in the United Kingdom took their own lives by hanging in mental health units; five were GMMH patients; The foundation itself said this meant it had 26% of such deaths in the entire country.

If you are experiencing distress or despair, details of help and support in the UK can be found at: BBC Action Line.