A young patient living with mental health issues posed “no risk to himself or others” and seemed “excited” for unescorted leave just hours before his body was found in a wooded area, an inquest has heard.
Ty Channce, 20, was a patient at Roseberry Park Hospital in Middlesbrough, where he was sectioned under the Mental Health Act following an attack on a family member - and lived with psychosis and schizophrenia.
He was at the hospital run by Tees, Esk and Wear Valley Trust until his death on April 28 2021.
The inquest at Teesside Magistrates Court heard that Mr Channce was found dead by a member of the public at about 6pm on the day of his death after he failed to report back to the hospital where he was last seen by staff more than three hours earlier.
Ty Channce and his mum, Cheryl Allan. (Image: CHANNCE FAMILY)
The inquest was told on Monday, Mr Channce was given unescorted leave on the date of his death, meaning he was allowed to leave the grounds.
His family were not informed of this leave, and they told the inquest on Monday they believed he was “not ready” for the outing.
The hearing was told on Tuesday that current and former staff at Roseberry Park said he “posed no risk to himself or others” in a mental health assessment made just hours before he went missing.
Stephanie Mulroy, who was Mr Channce’s named nurse at Roseberry Park from October 2020 until his death, told the hearing Mr Channce liked to “keep himself to himself”, spending much of his time in his room with his curtains closed.
This was “not unusual behaviour” for Mr Channce, according to Ms Mulroy who explained that he was welfare checked each hour and had “meaningful contact” with a staff member each day as well as being offered one-to-one chats.
Questioning Ms Mulroy, barrister Lily Lewis on behalf of the Channce family drew attention to documents that had “no reference” to Mr Channce being offered one-to-one chats.
She said “lessons have been learned” since then.
Ms Mulroy said in the weeks prior to their last contact on April 23 Mr Channce was planning for the future.
He had also expressed positive interest in the wind turbine industry on his “discharge pathway”, as it was hoped he could have left the facility by summer 2020.
Regarding concerns from loved ones about Mr Channce’s mental health leading up to his death, Ms Mulroy said: “If they were raised, they were never brought to my attention”.
Ward Manager Vanessa Omonie, who has worked at Roseberry Park for the last 25 years, saw and spoke to Mr Channce on the day he died, describing him as “excited” for his leave which was believed to have been granted as part of his “discharge pathway”.
Ms Omonie said: “There was no cause for concern about his presentation. He didn’t present as a risk. Giving him leave was the decision at the time that felt right.
“He was waiting for leave and for the plan to be submitted. He kept asking how far along we were and he looked like he was looking forward to leave.”
The inquest also heard about arrangements for leave on April 28 as Mr Channce was under supervision by the Ministry of Justice following an attack on a family member.
According to their guidance, the inquest heard that unescorted leave had to be introduced “gradually”.
Ms Omonie was questioned on this as it was previously told that Mr Channce’s last unescorted leave in August 2020 resulted in a breach in which he did not attend college.
She told the hearing: “At the time (April 2021), it was thought best based on his presentation. Two hours based on his previous leave seemed gradual.”
Regarding the fact his family were not told of his leave, Ms Omonie said there was an “assumption” that Mr Channce would tell them, and it was “not hospital policy” to do so.
The court also heard about Mr Channce’s course of medication, which he was allowed to self-administer in his room on the condition he was spot-checked.
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Following his death, 15 pills were found in the safe inside of his room and patient records revealed that Mr Channce did not receive his scheduled 4-day medication on April 24 – four days before he passed away.
A TEWV trust investigation found that these “spot checks” were not completed and there was a “miscommunication” between pharmacy staff and nurses regarding who was responsible for these.
The inquest continues.
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