The Prestwich mental health unit where a teenager died must address concerns or risk future deaths, says coroner.

Rowan Thompson, 18, died at North Manchester General Hospital following a seizure at the Gardener Unit at Prestwich Hospital on October 3, 2020.

An inquest found that Rowan, who was non-binary, died from a cardiac arrhythmia and severe hypokalaemia of an unknown cause. A jury ruled that their death was “contributed to by neglect” due to failure by Northern Care Alliance to communicate the findings of a blood test.

An inquest at Rochdale Coroner’s Court heard that Rowan died just hours after a blood test conducted by Salford Royal Hospital found they had dangerously low levels of potassium.

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Jurors heard that laboratory staff at Salford Royal Hospital, part of Northern Care Alliance NHS Foundation Trust, made several attempts to contact the Gardener Unit with the urgent blood test results, but ultimately failed to do so.

It was also heard that staff on the ward had falsified observation records on the day of Rowan’s death but agreed "there was no evidence to indicate that any such failure in this regard caused or contributed to Rowan’s death".

Based on the inquest’s findings, senior coroner Joanne Kearsley, has written to the Chief Executives of both Greater Manchester Mental Health Trust (GMMH) and NHS England with recommendations to prevent future deaths.

The report, dated November 2022 and published earlier this month, said: “During the court of the inquest the evidence revealed matters giving rise to concern. In my opinion there is risk that future deaths will occur unless action is taken.”

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It continued to say that the “system by which observations and documentation are audited lacks rigour and is ineffective.

“At the time of the CCTV review and investigation following Rowan’s death there was a missed opportunity for management to understand the gravity and nature of the situation.

“There was no higher-level investigation [into] whether the staff who failed to complete observations/falsify records when working weekends rather than during the week.

“Whether there was any correlation between missed observations/falsifying of records and shifts when there was no duty manager or ward manger on duty.”

The report also states that a lack of experienced staff on duty on the ward on the day of Rowan’s death “was a concern” as evidence heard in court suggested a more experienced nurse was always required on this unit.

At the time of their death, Rowan had been due to stand trial accused of murdering their mother Joanna Thompson in July 2019, the BBC previously reported.

At the hearing on Tuesday, October 25, primary nurse Jennifer Kearns told the inquest Rowan was “a great person".

“We got on well,” she said, “[Rowan was] so funny, so energetic, great sense of humour, I’ll never meet another person like Rowan again, so intelligent.”

A spokesperson for Greater Manchester Mental Health NHS Foundation Trust said: “Following the inquest, we carefully considered the Coroner’s Regulation 28 Prevention of Future Death Report and provided our formal response in December 2022. 

"We made a number of improvements to our observations procedures, which we are reviewing and developing on a continuous basis.

“Our thoughts and sympathies remain with Rowan’s family and all who cared for them.”