Overview
- Cerys Lupton-Jones, 22, died in May 2022 after tying a ligature, with the coroner recording a narrative conclusion that her death was contributed to by neglect and that her intention was unclear.
- The coroner identified a gross failure to provide basic medical attention following an earlier ligature incident and said she should not have been left alone on the short-staffed ward.
- Evidence described a culture of falsified observation logs, with CCTV showing Cerys entered a bathroom at 2:54pm and was found unconscious around 3:20pm, contradicting written checks.
- A clinical note written at 7:39pm was criticised for presenting a very different picture of events, and nurse Thaiba Talib has referred herself to the Nursing and Midwifery Council following the coroner’s recommendation.
- Greater Manchester Police and the Crown Prosecution Service brought no charges, and the trust said it has implemented changes including digital observation recording, CCTV on all wards, quality matrons, new leadership, and the replacement of Park House with the North View hospital.