The father of a teenager who killed their mum said 'there's nothing to forgive' as he slammed medical failings which led to the 18-year-old's subsequent death.
A breakdown in communication which stopped vital blood test results reaching a mental health unit in Prestwich, Bury, contributed to Rowan Thompson's death, jurors ruled after an inquest last month.
Rowan, who identified as non-binary and used the 'they' pronoun, was an inpatient on the Gardener Unit, which provides care for young people with serious mental illnesses or suspected psychiatric disorders. Rowan died aged 18 on October 3, 2020 - just four days before they were due to stand trial for the murder of their mum, Joanna Thompson.
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In July 2019, aged 17, Rowan inexplicably strangled her in her front room before returning to stab her more than 100 times. The teenager then calmly dialled 999 and told police: "Bring a body bag."
Rowan's father Marc Thompson, originally from Tyldesley, Wigan, has now spoken out for the first time and, using the pronoun 'he' for Rowan, said: "There's nothing to forgive Rowan for. He was very ill when he killed his mother and he needed support and help.
"He had no idea what he was doing, and he was filled with remorse and grief following her death. He was in a unit where he should have been receiving specialist support. But he died needlessly.
"If the blood test results had been addressed, Rowan would have been admitted to hospital for urgent treatment and the likelihood is my son would still be alive today. He was failed catastrophically by the very people who should have been caring for him."
In a six day-long 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 the Prestwich unit in time to save their life. Rowan died following a seizure the next day.
After five hours of deliberations, the jury concluded the lack of timely communication on Rowan's blood test results contributed to their death. They also ruled it amounted to 'neglect' - meaning 'a gross failure to provide basic medical care' as a result of the failure.
The inquest heard 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. The coroner said the weekend 'tragically ended with Rowan killing their mum and phoning the police', leading to Rowan being detained under the Mental Health Act and transferred to the medium-secure Gardener Unit in Prestwich.
Three young people have died at the Prestwich site in less than a year and an independent review is underway. Mr Thompson, 53, now and living in Wakefield, West Yorkshire, said of the killing: "I was in total shock. I couldn't believe what I was being told. Rowan was not violent and never had been. He clashed a lot with his mum, but he was never aggressive."
When Rowan was growing up, he said they were 'a normal, happy family'. "Rowan was a happy kid, he loved climbing and fencing," Mr Thompson said. "He had a very dry sense of humour. He loved Spike Milligan. He was a little bit geeky, something he was conscious of."
He said he could pinpoint the moment Rowan started having problems - aged 14 after a relative committed suicide. Six weeks on Rowan, who was born Ben, tried to take their own life and revealed they were being bullied at school, Mr Thompson said.
He said Rowan was admitted to the Priory and afterwards came out as non-binary, changing their name from Ben to Rowan. "Rowan began wearing nail varnish and dyed his hair. He was finding himself. He was really upbeat, he was a unique child, and I was very supportive of him. He didn't attempt suicide again, but did start self-harming and had some more psychiatric care before he came to live with me."
Mr Thompson said there was no hint of what was about to unfold when Rowan went to see their mum. "We will never know what happened to make Rowan snap the way he did. It is my belief they had some sort of argument regarding his mother wanting to enroll him at a college near where she lived. Rowan was clearly very unwell and this hadn't been picked up despite his previous psychiatric assessments.
"Rowan was sectioned and I visited three or four times a week. He attended college at the unit and studied three A- levels. He had a lot of anxiety about what he had done. But he was also very positive about getting better and he engaged with the staff and with his teachers. He didn't remember the attack on his mother, but he was filled with grief.
"I couldn't ask him about it at all because I was warned anything he said could be used in court, and so we didn't discuss it.
"I had concerns about the unit. There were not enough staff, my time with my son was restricted, and I felt my complaints were not being properly addressed. I didn't feel Rowan's needs were being met. Even something simple, like me taking a protein bar in for him, was not always permitted. Communication between me and the staff, and also between the staff, was poor."
Rowan started losing weight, the inquest heard, and in October 2020, staff at the unit took blood tests which were sent to Salford Royal.
Results showed Rowan was suffering from 'severe hypokalemia', a condition which causes low potassium levels in the blood. But, heard the inquest, no-one from the hospital called Rowan's doctors to make them aware of the results because they held an out-of-date phone number. The inquest heard the results should have been communicated verbally 'within two hours'.
Senior medics said at the inquest 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's switchboard was also for Skype voice messages rather than written emails.
The inquest heard Rowan was last seen out of their room on 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 were found to have either falsified or failed to correctly carry out observation checks on the ward, the coroner was told.
Mr Thompson said: "Rowan should have been admitted to hospital for urgent treatment and the likelihood is that my son would still be alive today. He, and other young people, are being failed by the very services which are there to protect them. Mental health provision for young people ought to be a priority in our society.
"I will never get the answers I need. But I have to look to the future and by speaking out I hope that things will change for other families and other vulnerable children."
The Manchester Evening News contacted Greater Manchester Mental Health NHS Foundation Trust for comment.
Gill Green, Chief Nurse, said: "We continue to express our heartfelt condolences to Rowan's family, friends, and all who have been affected by this tragedy. We fully accept the findings of the jury and H.M Coroner, and apologise wholeheartedly for the shortcomings identified in the care and treatment provided.
"Since the tragic incident, we have implemented a number of significant changes to improve patient safety, in areas including observations, safe staffing, and communication with our system partners. However, we recognise there is more to be done to improve our services, and this remains our top priority. It would be inappropriate to comment further until we have properly considered and responded to the Coroner's request under Regulation 28 (PFD)."
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