A mental health trust assured an inquest that lessons have been learned after one of their young patients was found dead in a wooded area whilst on unescorted leave.

Ty Channce, 20, was under the care of Tees, Esk & Wear Valley Trust (TEWV) at Roseberry Park Hospital in Middlesbrough from 2018 until his death on April 28, 2021.

Mr Channce was detained at the hospital under the Mental Health Act following an attack on a family member and lived with psychosis and paranoid schizophrenia.

The Northern Echo: Ty Channce and his mum, Cheryl Allan.Ty Channce and his mum, Cheryl Allan. (Image: CHANNCE FAMILY)

An inquest into his death at Teesside Magistrates Court this week has so far heard that Mr Channce was allocated unescorted leave off the grounds on the day he died for the first time in 9 months.

A mental health assessment was undertaken by staff before he left the hospital at 3:30pm deemed that he “did not pose a risk to himself or others”, “facially bright” and seemed “excited” to leave.

Tragically, Mr Channce’s body was found by a member of the public less than three hours later in a wooded area in Nunthorpe.

Now, Alison McIntyre, Associate Director of Nursing and Quality today (February 14) spoke on behalf of TEWV trust and laid out steps that had been taken and “lessons” that have been learned following the death of Mr Channce including issues that have been raised in inquest proceedings.

She added: “As a result of Ty’s death, a full, serious incident investigation was launched.”

Upon medication practices, Ms McIntyre stated that Mr Channce’s situation was a “significant learning area for the trust” after 15 tablets were found in his locker following his death, of which he was trusted to take himself and “self-medicate”.

An investigation from the trust found that spot-checks were supposed to be carried out on Mr Channce to ensure he was taking his prescription. Due to a “miscommunication” between staff, these checks did not happen.

Further evidence revealed that Mr Channce was due to pick up medication on April 24 – four days before he passed away but failed to do so and this was not noticed by staff.

Calculations of medical records from December 2020 also found that Mr Channce should have received 286 anti-psychotic tablets over a 143-day period – but it was found that he received 232, enough for 116 days.

Barrister for the Channce family, Ms Lily Lewis asked Ms Mangan if Mr Channce’s non-compliance in medication could have increased his risk for suicide. She said: “Based on non-compliance, yes.”

Ms McIntyre confirmed that new medication practices have now been put into place, including a new electronic system, monitoring of keys to patient safes as well as extra keys.

She added that patients self-medicating and the lack of “spot-checks” on them was a “wider service issue” not just present on the Nightingale Ward.

Ms McIntyre added: “There is no evidence to support that [spot checks] were followed through.”

Another issue addressed by the trust was a lack of 1-1 engagement as the inquest heard that there was no record of Mr Channce being offered this by his named nurse, Stephanie Mulroy.

Ms Mulroy told the inquest on Tuesday (February 13) that this engagement was offered to Mr Channce but he always “declined” – yet this was not reflected in her paperwork.

She added that “lessons have been learned” since then.

Ms McIntyre said: “About meaningful one-on-one care with his named nurse, there is a lack of evidence that he was undergoing this.”

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She continued to say that as of November 2021, staff must record that 1-1 engagement is offered even if, like in the case of Mr Channce, it is declined.

Staff must also record a lack of engagement and show work attempting to improve this engagement.

The TEWV statement closed by saying that they are “confident” provisions put in place will lead to improved patient care in the future.

The inquest continues.