GMP is opening a new investigation into the death of a teenager in hospital after the coroner intervened

Greater Manchester Police have opened a new inquest into the death of teenager Charlie Millers following a coroner’s intervention.

The 17-year-old trans boy from Stretford, Trafford, was found unresponsive in his room with ligature injuries late on the evening of 2 December 2020.

He died five days later after suffering a hypoxic brain injury in the incident at the Junction 17 mental health unit on the site of the former Prestwich hospital, run by the Greater Manchester Mental Health Trust (GMMH).

An inquest was held in April into Charlie’s death – an inquest being a public hearing to establish the facts of a sudden, unexpected or violent death – which concluded that he did not intend to take his own life.

Afterwards, the MEN can reveal, Senior Coroner Joanne Kearsley wrote to Greater Manchester Police saying she had “ongoing concerns” about the evidence given to the hearing, suggesting the force should look at the case again.

Now GMP have confirmed they have re-opened the investigation and will speak to “additional” witnesses. This is the third time the force has investigated Charlie’s case.

GMP first investigated Charlie’s death soon after but found nothing untoward. But in January 2023, when the inquest hearing first opened, Ms Kearsley told the court that questions had been raised about whether some hospital documents “may have been altered” since Charlie’s death.

This prompted Detective Superintendent Lewis Hughes to ask for the hearing to be adjourned so GMP could review its original investigation. He added that some staff working for the hospital trust may have to be interviewed under caution as part of their inquiries.

Postponing the inquest, Ms Kearsley said she was “not satisfied” with the initial investigation by Greater Manchester Police, asking the force to “engage” with the Care Quality Commission (CQC) on their findings and determine whether a subsequent CQC was need investigation.

But in January 2024 the police, after seeking investigative advice from the CPS, said there was insufficient evidence to seek a prosecution for aggravated manslaughter. Police would go on to tell the inquest, when it reopened three months later, that “there is no evidence that the documentation was altered with any malicious intent”.

The jury at Charlie’s inquest ultimately found that the lack of consistent, individualized medical care likely “contributed to his death.”

Jurors also found that Trafford council services did not communicate effectively enough with each other and did not give Charlie’s mother the “practical support” she needed as her mental health deteriorated, without enough help in community.

They also said he should have been subject to a “care protection plan”. Meanwhile, jurors concluded that GMMH’s observation system, where staff checked on Charlie during his stay on the wards – including when he was fatally injured – was not “robust enough” and was undertaken ” inconsistent at best”.

Following the hearing, Chief Coroner Joanne Kearsley told jurors she would be writing to the Home Office, the Department of Health and Social Care and agencies in Greater Manchester for their responses to the case, adding: “If there is effective learning from this. deaths, it must be done quickly”. A month later, she also wrote to GMP, triggering the new investigation.

In April, Charlie Millers mother Sam vowed to continue her “fight for justice” – and called for a public inquiry into an NHS trust – after the inquest jury concluded she did not intend to take her own life and identified its shortcomings. care.

At the time of his death, Charlie was on a strict observation regime where he had to be checked every five minutes, the inquest heard.

But during the hearing, coroner Joanne Kearsley raised questions about police findings about whether Charlie was being monitored by mental health staff every five minutes – a high level of observation to prevent self-harm – under his care plan.

Ms Kearsley told the court she had not been provided with the five-minute observation recordings – referred to as the ‘one in five’ documents.

And evidence presented during the investigation showed that the wrong timesheets were filled in by staff doing the five-minute checks, while in addition staff were named as doing the checks when they were in fact completed by others .

The court heard that even after a further investigation, not only did GMP “never see any of the one in five documents”, officers were “not aware” that mental health staff at the unit were supposed to complete them.

The inquest would go on to find that the police re-investigation concluded “that one in five observations were made by staff on December 2, but there is no documentary evidence to support this”.

Police said they based that conclusion on interviews with bank support worker Harry Osemwige, who claimed to have been making the five-minute observations from 10pm on the night of December 2 and that he was the staff member who discovered the Charlie unconscious before being. rushed to the hospital.

In the latest letter to GMP, Ms Kearsley describes how, although the inquest jury found that Charlie was “in fact” being checked every five minutes, she has concerns arising from the idea that staff were also checking other patients. every 15 minutes at the same time.

“While I acknowledge the jury’s conclusion, it raises an important issue that I do not think was considered as part of any investigation,” she writes.

“If (nurse) Donald (Agho) and Harry were completing 1:5 checks on Charlie at these times, then they must have also carried out 1:15 checks on other patients.”

She says it does not appear to have been considered during the police investigation whether this was appropriate working practice and in line with the Trust’s observation policy – or whether this was a safe system for observing Charlie and other patients .

She adds “importantly” it was not considered whether “this was even possible, given that they have to go into isolation to observe and see other patients while seeing Charlie (who the evidence suggests was in the room with the door closed) every five years. minutes.”

She concludes: “Given my continuing concerns about the evidence heard in court, I refer this matter back to GMP to consider the above points.”

Detective Superintendent Chris Bridge from GMP’s Serious Crime Division said: “First and foremost, our thoughts are with Charlie’s loved ones following his devastating death.

“Following evidence heard during the inquest, the coroner expressed concern that there were further opportunities to investigate the circumstances of Charlie’s death which were not fully undertaken during our original investigation. We understand that this will have caused additional distress to Charlie’s family and we apologize for that.