A 17-year-old trans boy who killed himself on a mental health ward felt “worthless” and “could not think of anything positive about himself” shortly before he died, an inquest heard.
Charlie Millers, from Stretford, had been bullied at school and misgendered by healthcare staff in the five years up to his death and he struggled with his mental health, Rochdale coroner’s court heard.
He was found unresponsive in his room on Prestwich hospital’s youth mental health ward, Junction 17, on 2 December 2020, and taken to Salford Royal Infirmary where he died five days later of a brain injury.
He was the third young person to die at the understaffed hospital in less than a year.
The inquest, which was delayed because of a police investigation into whether records had been tampered with, heard how Charlie had experienced behavioural issues since primary school and mental ill health since the age of 11, culminating in self-harm and a number of suicide attempts, which were getting worse as time went on.
Dr Laura Eccleston, the clinical psychologist in charge of the ward, described Charlie as a “lovely lad, really cheeky and so caring”.
“He had really big feelings of shame and struggled to experience a feeling of self-worth,” she told the senior coroner, Joanne Kearsley.
Eccleston said she was left traumatised by Charlie’s death after what had been a difficult year struggling with staff shortages. “I wanted to do my best for all the young people on the ward,” she said. “I was stretched and it was hard.”
When asked by the family’s barrister if she thought Charlie’s mental health had worsened as a result of being on the ward, she said: “No one wants a child to be in an inpatient setting.”
But she admitted the unit was “in some ways causing harm to Charlie” as he self-harmed more while in hospital as he did not want to do it around his family.
The inquest also heard from Dr Polly Carmichael, a consultant clinical psychologist who at the time oversaw the Gender Identity Development Service (Gids), which Charlie had been referred to when he was nearly 14.
Gids was run from the Tavistock and Portman Centre in north London, which closed last month after an interim report found the clinic to be “neither safe nor viable” due to its long waiting list.
She said Charlie, who had been under the care of the Leeds Gids service, was a “complex” case and that his mental health issues and the fact that he was autistic and struggled to articulate his feelings were preventing him from being able to access puberty blockers to treat his gender dysphoria.
The drugs are prescribed to delay puberty to give an adolescent the chance to think about whether to pursue gender affirming hormones. The vast majority of children who take puberty blockers go on to take gender affirming hormones, such as testosterone, as adults.
She said there were “various references in our notes to difficulty putting words to his feelings” and that his mental health would have needed to be stable before he could access drugs.
She added: “For young people with autism, that would without doubt slow down the process.”
Charlie had complained about how slow his treatment was, she said, and she added that it was a “tragic reality” that Charlie was facing having to be treated at the adult service because he was 17, which would have made care more difficult to access.
The inquest continues.
In the UK and Ireland, Samaritans can be contacted on freephone 116 123, or email jo@samaritans.org or jo@samaritans.ie. In the US, you can call or text the National Suicide Prevention Lifeline on 988, chat on 988lifeline.org, or text HOME to 741741 to connect with a crisis counselor. In Australia, the crisis support service Lifeline is 13 11 14. Other international helplines can be found at befrienders.org
