A breakdown in communication which stopped vital blood test results reaching a Prestwich mental health unit contributed to a teenager's death, jurors have ruled. Rowan Thompson, who was an inpatient on the Gardener Unit, died aged 18 on October 3, 2020.
In a six-day inquest held at Rochdale Coroners Court, jurors heard that Rowan had 'severely low' levels of potassium before their death, but old out-of-service phone numbers and email issues meant blood test results were not communicated from Salford Royal Hospital to Prestwich in time to save their life. Rowan, who identified as non-binary and used the pronoun 'they', died following a seizure the next day.
Members of the jury were sent out to deliberate this morning (October 31) and, after five hours of discussions, concluded that the lack of timely communication on Rowan's blood test results contributed to their death. They also ruled that this amounted to 'neglect' - meaning 'a gross failure to provide basic medical care' as a result of the failure.
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The inquest heard that Rowan, who was diagnosed with autism and depression, was first admitted to a mental health hospital after attempting suicide in 2016. Following a second admission while living with their mum in southern England, Rowan moved to Barnsley, South Yorkshire, to live with their dad.
Rowan visited their mum for a weekend shortly after their 17th birthday. Summing the evidence up to jurors this morning, coroner Joanne Kearsley said the weekend 'tragically ended with Rowan killing their mum and phoning the police', leading to them being detained under the Mental Health Act and transferred to the medium-secure Gardener Unit in Prestwich.
The court heard Rowan 'felt they had gained weight' on the Gardener Unit due to 'sugary treats', and they said they wanted to embark on more exercise and focus on three meals a day. Rowan began losing weight, but insisted to medics that they had not been inducing their own vomit.
On September 25, 2020, Rowan collapsed in an episode 'they had not had before', the court heard. Following tests, Rowan was found to have low blood pressure, which was linked to an increase in their trazadone medication.
A week later, Rowan had a blood test to establish a reason for their weight loss, which showed up 'severely low' potassium levels - a condition known as 'severe hypokalaemia'. The sample was taken from Prestwich to Salford Royal Hospital on October 2, 2020. The results were available by the early afternoon and the inquest heard that the results should have been communicated verbally 'within two hours'.
Dr Allamedine, clinical director at Northern Care Alliance, explained that an IT issue meant the results were not transferred electronically to the Gardener Unit. Both phone numbers held at Salford and recorded on the Gardener Unit's website were also out of service, while an email address given by the Prestwich Site switchboard was also for Skype voice messages rather than written emails.
The results finally reached the Gardener Unit on October 5, 2020, but this was two days after Rowan's death. Toxicologist Dr Stephen Morley told the inquest that Rowan's potassium levels had been 'life-threatening' but a timely admission to hospital could have saved their life, while Rowan's psychiatrist Dr Malik said he would have sent them to A&E straight away had he received the results at the right time.
The court heard Rowan was last seen out of their room in the morning of October 3, 2020, as they went to do some laundry. Just nine out of 24 observations between 7am and 12.45pm were carried out and five members of staff at GMMH were found to have either falsified or failed to correctly carry out observation checks on the ward - but coroner Ms Kearsley told jurors this did not lead to Rowan's death.
The jury concluded that Rowan had been found having a seizure at 12.54pm and CPR began three minutes later. A 999 call was made at 1.03pm and paramedics arrived at Prestwich Site at 1.06pm, but they were only able to find their way to Gardener Unit by 1.26pm.
Rowan was transferred to North Manchester General Hospital, where they were pronounced dead at 2.25pm. Following deliberations, the jury gave the cause of Rowan's death as cardiac arrhythmia due to severe hypokalaemia of unknown cause.
While finding the breakdown in communication over Rowan's blood test results had contributed to their death, jurors also agreed the falsification of observation checks on the morning of their death were matters of fact in the case, although this did not contribute to Rowan's death.
Following the jury's findings, coroner Ms Kearsley confirmed three issues she would raise in a prevention of future deaths report - including the ability for paramedics to navigate Prestwich Site, which had caused a delay, and whether blood test forms had been changed to include the correct contact details between GMMH and Northern Care Alliance.
Ms Kearsley also criticised the lack of CCTV being checked for observations made by staff at Prestwich Site, noting a previous audit found 11 members of staff had not carried out checks properly. She said: "Whilst I heard evidence around the auditing of observation sheets, one questions the worthiness of those if the CCTV is not checked also."
During the inquest, Rowan's father Marc Thompson described them as an 'enigma' and a 'quirky individual', with a 'great sense of humour' and a 'strong sense of right and wrong'. Following the inquest, Mr Thompson told the Manchester Evening News : "I’m pleased that through the coroner's investigation we have identified a cause of death which brings me some solace, but tempered by the knowledge that Rowan’s death was totally avoidable - culminating in the jury concluding there was a 'gross failure to provide basic medical care' (neglect).
"Rowan was a brilliant and unique individual and not a day goes by that I don’t think about them."
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