Greater Manchester Mental Health Trust's (GMMH) investigation into the death of Charlie Millers has been described as 'lacking' after bosses failed to speak to all staff members working on the ward at the time when the teenager was fatally injured there.
The 17-year-old trans boy died five days after he was found unresponsive in his room on mental health unit Junction 17 at the site of the former Prestwich Hospital, run by Greater Manchester Mental Health Trust (GMMH) late in the evening of December 2, 2020.
Mental health unit managers were also told to audit observations being done on patients staying on wards after fears they were not being done – only for those audits to also go uncompleted, an inquest has heard.
GMMH managers were instructed to carry out daily audits of the regular checks being carried out on patients by ward staff. The audit programme followed concerns in October 2020 that those regular checks, where patients are observed a set number of times an hour in accordance with their condition, were not accurate or simply not being done.