Exclusive report from the M.E.N's chief reporter Neal Keeling
Greater Manchester Police has opened a new investigation into the death of teenager Charlie Millers following a coroner's intervention.
Following that, the M.E.N can reveal, Senior Coroner Joanne Kearsley wrote to Greater Manchester Police saying she had 'ongoing concerns' about evidence given to the hearing, suggesting the force should look again at the case. Adjourning the inquest, Ms Kearsley said she was ‘not satisfied’ with the initial investigation carried out by Greater Manchester Police, calling for the force to 'collaborate' with the Care Quality Commission about their findings, and establish whether a subsequent CQC investigation was needed.
They also said he should have been the subject of a 'care protection plan'. Meanwhile, jurors concluded GMMH's observation system, where staff checked on Charlie during his stays on wards - including at the time he was fatally injured - was 'not robust enough' and was undertaken 'inconsistently at best'.
But during the hearing, questions were raised by coroner Joanne Kearsley about the police's findings on whether Charlie was being checked on by mental health staff every five minutes - a high level of observation to prevent self-harm - as per his care plan. The inquest would hear that the police reinvestigation concluded ‘that the one-in-five observations were being conducted by staff on December 2, but there is no documentary evidence to support that’.
"If Donald and Harry were completing the 1:5 observations on Charlie at these times, then they must also have been completing 1:15 checks on other patients."
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