Sam Copestick was aged 24 when he died in May 2019 from self-inflicted injuries, three days after he had absconded from the care of his mental health unit at Birch Hill hospital in Rochdale. He had been diagnosed as a paranoid schizophrenic in June 2017.
The family of Sam Copestick was represented by Ruth Bundey of our team at the Inquest hearing at Rochdale Coroner’s Court in October 2021.
Sam Copestick was a popular university student when his mental health started to deteriorate quite suddenly, and he was eventually admitted to Prospect Place in June 2017, a secure unit within the Pennine Care NHS Foundation Trust. This was after having spent seven months in an intensive care unit after he threw himself under a train.
The Inquest heard that Sam’s health went downhill rapidly after his brother Matthew died suddenly in January 2019, at which point Sam’s mother, Helen McHale, stressed to his mental health team his deteriorating health. Sam had a care plan which detailed the requirement for any escorted leave out of the hospital to involve two nursing assistants as escorts, one of which had to be male. Sam’s mother made a series of complaints with concerns over Sam’s care plan, which included a meeting in April 2019 where improvement recommendations were agreed between all parties. One of these recommendations was that Sam’s leave should be carefully managed.
In May 2019 Sam made an “out of the blue” request to go on an escorted leave visit, which was granted. One female nursing assistant accompanied Sam on the visit, during which he absconded from her care. The nursing assistant had no phone or radio with her and therefore had no means of responding. Sam was found and subsequently died in hospital with “injuries sustained following self-suspension from a ligature while suffering delusions due to paranoid schizophrenia.”
A Jury sat during Sam Copestick’s Inquest and returned a verdict that his death was contributed to by the neglect of Pennine Care NHS Foundation Trust. This came from multiple failings including:
- Failing to give adequate weight to Sam’s mother’s concerns regarding his mental health.
- Failure to check the Care Plan which instructed that two members of staff were required to escort on granted leave visits. The nursing assistant also failed to take a phone or radio with her on the visit.
- Failure to implement recommendations following previous complaints by Sam’s mother regarding underestimation of risk.
- Failures around planning and risk assessment prior to the leave visit.
Following the Inquest verdict, Ison Harrison’s 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.”
Read our Sam Copestick Inquest News and Coverage: