Inquest finds Stretford transgender teen did not intend to end his life
17-year-old, Charlie Millers, died from injuries sustained whilst a mental health patient at Junction 17 ward, Prestwich Hospital in December 2020
Last updated 25th Apr 2024
An inquest has found a transgender teenager from Stretford did not intend to take his own life, after harming himself while in a mental health ward.
Charlie Millers, a 17 year old transgender boy, died from injuries sustained whilst a mental health patient at Junction 17 ward, Prestwich Hospital in December 2020. Charlie was one of three young people to die at the hospital in less than a year.
The inquest examined the circumstances and care provided by Greater Manchester Mental Health NHS Foundation Trust, Trafford Borough Council and five other Interested Persons.
Charlie was from Stretford in Manchester. He was a talented artist who loved Morris dancing, football and animals. His family describe him as ‘an amazing human’ with a ‘smile that affected and melted away a thousand hearts’, who made time for others regardless of how much he was struggling.
Charlie had experienced behavioural issues since primary school and mental ill health since the age of 11. He was diagnosed with ADHD and autism. He came out as a transgender boy around this time. As he got older, Charlie’s mental health deteriorated further, including serious self-harming behaviour.
At the time of his death, Charlie was receiving gender affirming healthcare and attending a gender clinic. Charlie experienced some bullying at school as a result of his gender identity, which contributed to his poor mental health.
Charlie was receiving support from Trafford Social Services. However, due to significant deterioration in his mental health, he was admitted under section to Junction 17 on three occasions, including after multiple self-harming incidents, in the months and weeks before his death. He was frequently discharged, only to be returned to the ward shortly after.
Charlie was admitted to the ward for the final time for six weeks from 20 October 2020, with occasional days of leave. On 12 November 2020, Charlie was taken to A&E after self-harming. He was supposed to be on 1-2-1 observations when he returned to the ward.
On Monday 30 November 2020, Charlie self-harmed on the ward and was taken to North Manchester General A&E. Charlie returned to the ward two days later, after a night at home. That night, he self-harmed and was taken to Salford Hospital. He died five days later on 7 December 2020.
In the month before Charlie’s death, his mother filed two complaints to Care Quality Commission about the ward.
The inquest initially opened in January 2023, but was adjourned due to a Greater Manchester Police investigation into the circumstances around Charlie’s death. There was insufficient evidence to meet the criminal standard for Gross Negligence Manslaughter and as such, no criminal charges were brought.
Dr Arasu Kuppuswamy, Chief Medical Officer at Greater Manchester Mental Health NHS Foundation Trust, said:
“This was a tragic case, and our thoughts remain with Charlie’s family.
“We fully accept the inquest’s findings and jury’s conclusion.
A wide range of actions have already been taken to improve our inpatient mental health services both in response to Charlie's death, and as part of our wider improvement plan.
“This includes strengthened clinical leadership, new approaches to observing patients, training for staff, and weekly audits with learning shared across GMMH.
“We are developing a new electronic system to record patient observations digitally that will enhance the assurance process. This will feed into a central system to reduce errors, ensuring records are always up-to-date and available for care professionals looking after a patient.
“We know there is more work to do and will implement the coroner’s recommendations and continue to work with partners to improve care.”
“We understand nothing will bring Charlie back and are deeply sorry for Charlie's family and friend's loss.”