17 hours agoShareSaveAlison Holt,Social affairs editor and James Melley,Senior social affairs producerShareSaveFamily handoutWarning: The following article contains details about suicide which some may find distressingCerys Lupton-Jones pauses between two doorways.One door leads into a side room in the Manchester mental health unit where she’s a patient. The other leads into a toilet.The 22-year-old had tried to end her life just 20 minutes earlier – but no staff are seen on the CCTV footage from inside the unit.She hesitates for about 30 seconds, walking backwards and forwards. Then she enters the toilet and shuts the door.The next time she is seen on the footage, doctors and nurses are fighting to resuscitate her.Cerys dies five days later, on 18 May 2022.A coroner has concluded that some of the care Cerys was given at Park House, which was run by the Greater Manchester Mental Health NHS Foundation Trust, was a “shambles”.Staff were meant to be checking on her every 15 minutes.But the last recorded observation – at 15:00 – had been falsified, saying she had been seen in a corridor. CCTV shows at that point, Cerys was already in the toilet where she would fatally harm herself.A staff member who was supposed to be looking after her has now admitted to falsifying these records.Zak Golombeck, coroner for Manchester, said that if someone had stayed with her after the earlier attempt to take her life, what followed may never have happened. He said neglect was likely to have contributed to her death.Campaigners are calling for an inquiry into the number of deaths at the mental health trust and believe the services are in crisis.Greater Manchester Mental Health Trust said it “failed her that day, and we are so very sorry that we did not do more”.Family handoutCerys’s parents, Rebecca Lupton and Dave Jones, describe their daughter as a loving young woman who would do anything for her friends. She was studying to be a nurse and was months away from completing her degree, with a job lined up.She was autistic and had also struggled with her mental health since her teens.Her family, who lived miles away in Sussex, say the pandemic and the reduction in community mental health support exacerbated Cerys’s problems.The inquest was told Cerys had tried to take her life in the days running up to her death, spending time in A&E.She was then readmitted to Park House and put on one-to-one observations for a short time. Later, she was supposed to be checked by staff every 15 minutes.The inquest heard how, at about 14:35 on 13 May 2022, Cerys was found in a toilet by Mohammed Rafiq, a health support worker who had been assigned to check on her. Cerys had tried to hang herself.Mr Rafiq and the duty nurse, Thaiba Talib, intervened.However, the inquest heard the 15-minute observations were not then increased and staff had no proper conversation with her.The nurse told the inquest she did not believe Cerys meant to seriously harm herself.She told the coroner she chose not to increase observations on Cerys because she did not want her to feel punished, as she did not like being under observation.When asked by the coroner if she should have gone with Cerys to her room after the incident and check she was safe, Ms Talib answered: “In hindsight, yes.”Damning CCTV from inside the unit was described minute by minute in court.It showed Cerys going into the ward garden at 14:42. The observation record, which says at 14:45 she was in her bedspace, was described by the coroner as “not accurate”.At 14:54, Cerys walked into another toilet on the ward and closed the door.Yet Mr Rafiq told the coroner he remembered seeing Cerys at 14:57. He wrote in the observation notes that he had seen her at 15:00 “along the corridor, looking flat-faced”. He then went on a break. In reality, Cerys was still in the toilet.The coroner told Mr Rafiq that his recollections were wrong, and that he had “falsified” the observation records. Mr Rafiq responded: “I’m afraid so”.Mr Rafiq said other staff had shown him how to record observations every 15 minutes, even if he hadn’t done them at that time. “That’s how they did it and that’s how I did it”, he told the court.A new support worker took over the observations at 15:00. There was no verbal handover and, according to Mr Rafiq’s notes, Cerys had just been seen.The CCTV shows the new support worker checking on other patients. At 15:15 …
