Staff at mental health ward failed to carry out 15 minute checks on man before he died, inquest hears

Nursing staff responsible for a patient at a mental health ward failed to carry out the 15 minute checks he required - with log books on observations appearing to differ from CCTV evidence - an inquest jury has heard.

Lee Doherty was being treated at Prospect Place, Birch Hill Hospital, Rochdale, after being detained under the Mental Health Act. The 46-year-old, from Manchester, died on July 15, 2022 after he was discovered bleeding badly in his room.

Staff mopped up blood from the floor as CPR attempts were made. Paramedics arrived and Mr Doherty was declared dead. An inquest at Rochdale Coroners' Court got underway on Thursday (November 28).

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The court heard nursing staff failed to carry out checks every 15 minutes. Log books on observations appeared to differ from CCTV footage, the inquest heard.

Detective Inspector David Crewe from Greater Manchester Police told the court video evidence showed staff had not been checking on him with the regularity he needed.

CCTV time stamps indicated Mr Doherty was checked on by nursing assistant Sidrah Kazmi at 6.02pm the evening he died, the court heard. Another patient looked through his door window 18 minutes later, the court heard, as Mr Doherty gave them a 'thumbs up'.

It wasn't until 6.42pm - 39 minutes later - that Mr Doherty was again checked on by Ms Kazmi, the court was told. It was then, the court heard, Mr Doherty was seen bleeding badly.

Questioning DC Crewe, senior coroner Joanne Kearsley said: "From looking at the log it would appear as though these observations had been conducted as they should have been. It was only when you reviewed the CCTV that you realised that was not correct?"

DC Crewe replied: "That's correct ma'am, yes. We looked through the observations from 12pm. We noted that there appeared to be multiple missed observations during that period which would have been attributed to various members of staff."

Ms Kearsley said: "This was not just one member of staff who appeared to be missing observations." Mr Doherty had been diagnosed with paranoid schizophrenia. The risk of self-harm was deemed to be high, the inquest heard. He had a 4.8cm wound on his left leg which he would often pick at.

DC Crewe told the court a plastic knife and fork were seized from his room and that there had been blood 'splatters' on the walls, floor and around the toilet. The court heard that at the time of his death, he had been prescribed blood thinners and had cardiac conditions that could have posed a significant health risk.

Consultant pathologist Dr Charles Wilson told the court he believed that Mr Doherty's blood loss was likely to have been a significant factor in his death. He said Mr Doherty's risk of heart disease was high, meaning the organ would not be able to handle the stress of the blood loss as well.

The inquest before a jury continues