Rowan Thompson: Trust failures contributed to death - coroner
- Published
Communication failures at a mental health trust "probably caused or contributed to" the death of a teenager at a hospital, a coroner has said.
Rowan Thompson died at Greater Manchester Mental Health Trust's (GMMH) Prestwich Hospital in October 2020.
An inquest at Rochdale Coroner's Court heard poor communication led to the 18-year-old not being treated for "severely low" levels of potassium.
Rowan was one of three people who died in a nine-month period at the site.
The teenager, who identified as non-binary, was being held at the hospital's Gardener Unit, while on remand after being accused of murdering their mother Joanna in July 2019.
Mrs Thompson was stabbed more than 100 times at her home in Hambledon, Hampshire.
Rowan was found unresponsive in their hospital room days before their trial was due to begin and a day after having a blood test to test the potassium levels in their blood.
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The court heard that incorrect phone numbers and email contacts meant the results showing Rowan had low potassium levels were never sent to or received by anyone responsible for their care.
Forensic toxicologist Dr Stephen Morley previously told the inquest that results indicating a "severely low" level of potassium should be communicated within two hours "due to the risk of sudden heart rate issues or stopping breathing".
Dr Morley also said he was "at a loss" as to why Rowan had low levels of potassium, but indicated that their medication was not a contributing factor.
The inquest was told Rowan had blood tests at Salford Royal Hospital after collapsing and losing consciousness at the unit.
The court was told a psychiatrist at the unit believed that collapse could have been because Rowan's dosage of antidepressants had recently been increased.
Rowan's GP, Dr Isabel Nash, also told the court she would have reviewed Rowan's prescription for antibiotics if she had known about their low potassium levels.
Concluding that Rowan died as a result of cardiac arrhythmia with severe hypokalemia of unknown cause, coroner Joanne Kearsley said failures by GMMH and the Northern Care Alliance Trust, which runs Salford Royal, had "probably caused or contributed to" the teenager's death.
Addressing Rowan's family directly, she said their doctor had described Rowan as "unique and special".
She said they had been "much loved" by their grandparents and she could "only imagine how difficult the last two years have been".
"I hope this inquest can give you a little bit of closure and answer some of the questions you've had over the last two years," she added.
In a statement, Rowan's father Marc Thompson said the 18-year-old had been "a brilliant and unique individual" and "not a day goes by" when the teenager was not in his thoughts.
"I'm pleased that through the coroner's investigation we have identified a cause of death, which brings me some solace, but [that is] tempered by the knowledge that Rowan's death was totally avoidable," he said.
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- Published22 October 2022