Ison Harrison lawyer Ruth Bundey – a member of the INQUEST lawyers group – acted for the family at the inquest into the self-inflicted death of mental health inpatient Sam Copestick at Rochdale Coroner’s Court.

It was found that multiple care failings had contributed to Sam’s death in June 2019, at the age of 24, three days after he had absconded from care while on escorted leave from Prospect Place, a secure unit of the Pennine Care NHS Foundation Trust in Rochdale.

Sam Copestick was a popular university student when his mental health first started to deteriorate. He was eventually admitted to Prospect Place in June 2017 after having spent seven months in the Pennine Care Psychiatric Intensive Care Unit after he threw himself under a train. He was diagnosed with paranoid schizophrenia and his deterioration escalated from January 2019 when his brother Matthew died suddenly.

Improvement recommendations ignored

There was no obvious improvement in Sam’s long term mental health and in 2018 his mother, Helen McHale, raised concerns about the standards of his care to staff at Prospect Place and Sam’s terror that he would be killed if he were given leave from the ward.

Sam’s care plan allowed for escorted leave, but this had to be under the supervision of two care staff, one of which had to be male. His mother advised that his condition was getting worse.

However, on June 17th 2019 Sam made a request “out of the blue” to leave the unit on escorted leave, which was granted. But he was escorted by just one female staff member, who had no radio or phone and could not respond when Sam absconded. He died in hospital 3 days later as a result of “injuries sustained following self-suspension from a ligature while suffering delusions due to paranoid schizophrenia”.

sam copestick

Numerous contributory failings highlighted

The inquest ruled that Prospect Place were guilty of numerous failings which contributed to his death.

  • Failing to give adequate weight to Sam’s mother’s concerns regarding his mental health following his brother’s death
  • Failure to check the leave form which instructed that two members of staff were required to escort Sam
  • Failure to implement lessons of previous complaints by Sam’s parents regarding underestimation of risk
  • Failures around planning and risk assessment prior to the leave, including failures to complete and countersign the required risk assessment plan, insufficient information on the leave form, and inadequate signing of the leave description sheet.

The jury concluded that the death was contributed to by neglect.

Sam’s mother Helen McHale commented at the conclusion of the inquest:

“Looking after people who are mentally ill is challenging, requires care, patience, skill, and sometimes things go wrong. The continued nature of these failings, however, is far deeper and longer lasting than simple mistakes. Trying to get Sam’s distress and risk accepted was a constant battle. I know from talking to other carers and hearing other stories that these mistakes are repeated elsewhere. I truly hope these findings improve things for them. Given the continued inability to deliver some fairly simple changes, I have little confidence they will, but want to help in any way I can.”

Family “sad and angry”

Sam’s father, Lee Copestick, added: “In the last two and a half years of Sam’s life I slept a little easier believing he was in a safe place. Since Sam’s passing, I have been angry and deeply sad realising that was not the case. These feelings remain now that the court too has concluded that Sam’s death was preventable.”

Ison Harrison lawyer Ruth Bundey commented:

“It is beyond belief that senior Pennine staff ignored crucially informative and courteous emails, as well as calls, from Sam’s mother Helen, revealing her son’s increasing distress that if he went out on leave he would be killed. This followed two sets of admissions in the previous year that the Trust had not sufficiently listened to the family’s experiences. This devastating lack of respect ultimately led to Sam’s death.”

It is believed that in this case, mental health services crucially overlooked the valuable insights families can provide and it is widely felt that the care sector needs to make significant changes on a national scale, to ensure risks relating to an individual’s care plan are adequately managed and to avoid a repeat of this tragic case. Indeed, in accepting the failings and the inquest verdict, a spokeswoman for the Pennine Care NHS Foundation Trust said it offered its “deepest apologies to Samuel’s family”, adding “we are truly sorry about the failings and put an improvement plan in place straight after our investigation to try to ensure this never happens again.”

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