An inquest has revealed that a long-term mental health patient died at Birch Hill Hospital in Rochdale after a series of critical failures. Lee Doherty, 46, passed away on July 15, 2022, after a nursing assistant missed seven required 15-minute checks. The ongoing investigation at Rochdale Coroners’ Court has exposed systemic issues at the facility, including staff shortages and the falsification of patient records, raising serious questions about patient safety.
Inquest Uncovers Falsified Patient Records
During the inquest, jurors were presented with evidence showing significant gaps in the care provided to Mr. Doherty. He was supposed to be observed every 15 minutes, but these crucial checks were frequently missed. The court learned that there were major discrepancies between the observation logs filled out by staff and the actual events captured on CCTV footage.
Senior Coroner Joanne Kearsley directly addressed these failures while questioning Ieuan Thomas-Cole, the associate director at Prospect Place. She pointed out the widespread nature of the problem, stating, “There’s clear evidence that it happened, but there’s clear evidence that it happened by nearly every member of staff.” Mr. Thomas-Cole confirmed he was aware of the issues surrounding the falsifying of records at the facility.
Staffing Shortages and a Culture of Extended Breaks
A key factor contributing to the tragedy was a workplace culture where staff regularly took long breaks at the beginning or end of their shifts. This common practice meant that the ward was often left understaffed, falling below the minimum required levels for safe patient care.
Rosemary Thompson, a nursing assistant on duty at the time of Mr. Doherty’s death, admitted to missing seven consecutive checks between 1:40 PM and 3:20 PM. She told the court she was busy with other activities and confessed, “I actually didn’t know that I was supposed to be doing the observations.” When she realized her mistake, she admitted to rushing to complete the paperwork. “I panicked. I picked up the observations and started writing them down quickly,” she said. This was not an isolated incident, indicating a broader systemic failure.
The shift patterns at the facility were detailed in court, showing the planned staffing levels.
| Shift Type | Staffing Details |
| Day Shift (7:30 AM – 7:30 PM) | 2 nurses, 4 nursing assistants |
| Night Shift (7:30 PM – 7:30 AM) | 2 nurses, 2 nursing assistants |
However, the practice of taking extended breaks at shift changes often left the ward with minimal staff during these critical handover periods.
New Policies Introduced Amid Lingering Concerns
In the wake of Mr. Doherty’s death, Pennine Care NHS Foundation Trust has implemented changes at Prospect Place to prevent a similar tragedy. These new measures are intended to improve accountability and ensure observations are carried out correctly.
The key changes include:
- Staff are no longer permitted to take extended breaks at the start or end of their shifts.
- The nurse in charge is now required to countersign all patient observation logs to verify they have been completed.
Despite these new policies, Coroner Kearsley expressed skepticism about their effectiveness. She challenged the countersigning process, questioning how a nurse could truly verify the accuracy of a log that may have been falsified moments before. “If I lie on that document, then go to the nurse in charge and tick that box, she has no way of knowing. Is that fair?” she asked. Mr. Thomas-Cole conceded that her assessment was correct, leaving a question mark over the new system’s ability to prevent future record falsification.
Frequently Asked Questions
Who was Lee Doherty?
Lee Doherty was a 46-year-old man from Manchester who had been a long-term patient under the Mental Health Act. He died on July 15, 2022, while in the care of Prospect Place at Birch Hill Hospital.
What were the main failures in his care?
The inquest found that Mr. Doherty was not observed for a significant period, with a nursing assistant missing seven consecutive 15-minute checks. It also revealed a widespread culture of falsifying patient records and staffing shortages caused by break patterns.
What changes has the hospital made?
The facility has stopped the practice of staff taking long breaks at the start or end of shifts. It has also introduced a new rule requiring the nurse in charge to countersign observation sheets to ensure they are completed.
Are the new safety measures foolproof?
The Senior Coroner raised concerns that the new countersigning policy could still be bypassed. A staff member could potentially falsify a record and get it signed off without the supervising nurse being able to verify if the checks actually happened.
