Serious failings in the care of a student nurse on an NHS ward contributed to her death, a coroner has ruled. Cerys Lupton-Jones, 22, died on May 18, 2022, five days after she was found unconscious in a bathroom at Park House, a mental health facility in Greater Manchester. The coroner concluded her death was 'contributed to by neglect' and described the events leading up to it as a 'shambles'.
Manchester coroner Zak Golombeck found that Cerys died from the effects of strangulation after tying a ligature around her neck, but said her intentions were 'unclear'. The inquest heard there had been a similar incident 50 minutes earlier. Mr Golombeck said there was a 'gross failure' on the part of Greater Manchester Mental Health NHS Trust (GMMH) to provide basic medical attention following the first incident, and that Cerys 'should not have been left alone'.
The coroner raised concerns about a 'culture' of observation logs being 'falsified' while the ward was short-staffed. He said falsification meant staff were not aware of the actual time Cerys was last seen. CCTV showed she entered a communal bathroom at 2.54pm, 26 minutes before she was found unconscious. A nurse, Thaiba Talib, wrote a note after the incident that painted a 'very different picture' of events, and has referred herself to the Nursing and Midwifery Council.
GMMH accepted the coroner's findings and apologised to Cerys' family. Chief executive Karen Howell said improvements at the trust have come 'too late'. Cerys' mother, Becky Lupton, said the family was 'relieved' that neglect had been formally acknowledged. 'I think I can have happy memories of Cerys now,' she added.
