An inquest jury has found that neglect on the part of Greater Manchester Mental Health (GMMH) NHS Foundation contributed to the tragic death of Charlotte Parry who hanged herself at Wythenshawe Hospital in January 2022 at the age of 27
Charlotte was detained under the Mental Health Act 1983 on the Bronte Ward of Wythenshawe Hospital due to her high risk to self and diagnoses of Emotionally Unstable Personality Disorder, Obsessive Compulsive Disorder and Generalised Anxiety Disorder.
Charlotte was found hanged in her room having used an hessian bag for life and a chest of drawers.
Prior to this, Charlotte had already made multiple ligature attempts, including using a tote bag and twice using her drawers in December 2021.
The inquest heard that the drawers had been removed from Charlotte’s room in December 2021, however a decision had been made to return them to Charlotte on the 20th January 2022.
Charlotte had also been on 1:15 observations since the start of her stay, meaning that she was due to be observed every 15 minutes. However, on 28th January 2025, a decision was made to reduce Charlotte’s observation levels to “general”, meaning that observations would only be once an hour. Charlotte herself had raised concerns about this reduction in observations.
Assessments had been made to move Charlotte to a specialist therapeutic placement, however the Inquest revealed that no evidence of an application for this funding could be found, despite Charlotte having been accepted to a specialist placement in December 2021.
The jury in the inquest found a number of issues that had related to her death including in relation to her observation levels, the return of items used to ligature, delays in applications for funding for specialist treatment and ward systems for managing ligature risk, finding that these caused or contributed to Charlotte’s death.
The jury also made a number of critical findings in relation to the Trust as a whole, including that the systems in the Trust for managing ligature risk were not adequate, and that this possibly caused or contributed to Charlotte’s death. They further found that there were significant and systematic failures in the Trust and incompetence at a senior leadership level.
Carol Parry, Charlotte’s mother, said in a statement:
“We as a family are absolutely devastated. For the jury to conclude neglect by GMMH contributed to Charlotte’s tragic death makes this even more unbearable. To date, we have not received any sort of apology for their significant and systematic failures including numerous critical findings in relation to Charlotte’s care.
We would like to thank HM Coroner Mr Appleton, the jury and our legal team (Kelly Darlington of Farleys Solicitors and Lily Lewis of Garden Court North Chambers) for their professionalism and kindness. We are pleased that Professor Shanley and the CQC [Care Quality Commission] are closely monitoring GMMH’s practices and hope that changes continue to be made to protect other patients within their care.
We as a family are not making any further comment at this time as we continue to navigate life without our beautiful Charlotte.”
