Ty Channce inquest: TEWV patient died by suicide after care failings

Ty Channce was found dead hours after being released from a Tees, Esk and Wear Valleys (TEWV) hospital for the first time in nine months, on April 28, 2021.

Ty’s death was contributed to by failings in his care, a jury concluded on Thursday after a four-day inquest at Teesside Coroner’s Court.

On the day he died, the 20-year-old was granted unescorted leave off the grounds of Roseberry Park Hospital in Middlesbrough for the first time in nine months. The jury said the trust’s “failure to gradually introduce unescorted leave” contributed to his suicide.

Ty Channce with dad Carlton. (Image: FAMILY)

Failings ensuring Ty was taking his medication also contributed to him ending his life, as did “the negative impact of the Covid-19 lockdown restrictions on [his] mental health”.

In an emotional courtroom, Senior Coroner Clare Bailey fought back tears as she offered her condolences to Mr Channce’s heartbroken family.

Ms Bailey said: “I hope that this process [will] result in the better provision of care for future residents of the Nightingale ward – this will be part of Ty’s legacy.”

In a statement, Ty’s mum Cheryl, dad Carlton and step-dad John, said: “We fought for Ty. We set out to get justice for Ty. We are glad the jury saw how he had been failed.

Ty with step-dad John and mum Cheryl. (Image: FAMILY)

“We are fighting, not just for Ty, but for other families too. We hope this spares other families going through the pain and heartache of losing a child that we place in the care of the trust.

“He didn’t come home but he will live forever in our hearts. He is our heart.

“We lost a loving son and this has left a hole in our hearts that will always be there. We will always love you Ty.”

The family has today released new pictures of their beloved son.

The 20-year-old was granted unescorted leave off the hospital grounds on the day of his death, taking £60 to spend in a café.

Cheryl said Ty was said her son was a “bundle of joy” and brought “love and joy” into his family’s life. (Image: FAMILY)

After leaving the hospital at 3.30pm he was found hanged in woods at 6.29pm by a jogger, less than an hour after TEWV reported him missing to police.

Mr Channce had been a resident at Roseberry Park since 2018. He was detained there under the Mental Health Act after attacking his stepdad with a knife and lived with psychosis and paranoid schizophrenia.

His parents said TEWV failed to notify them Ty would be allowed out on the day he died, as they had been on previous occasions.

The family only learned of his release when they received a call warning them to “lock [their] doors” as he was missing, the court heard. A nurse told the inquest it was not policy but would have been “good practice” to tell the family of his release.

Ty with step-dad John Allan. (Image: FAMILY)

Ty had been allowed to leave hospital three days a week, for eight hours a day pre-Covid, but the family said his mental health had worsened in lockdown.

His family stressed that he was “not ready” to leave the grounds alone on the day he died, and the court heard he had last been allowed out some months previous, in November 2020.

But a risk assessment in the hours before his release staff believed he “posed no risk to himself or others” and was “excited to leave”.

The inquest heard the days’ leave was part of a pathway to him being discharged.

An inquest took place at Teesside Coroner's Court this week. (Image: Chris Booth)

His named nurse, Stephanie Mulroy, accepted he liked to “keep himself to himself”, but said this was not “unusual behaviour” for him. He was said to be “settled on the ward” and there were “no concerns regarding his presentation”, clinical lead nurse Michaela Mangan said.

It emerged on Wednesday Ty didn’t receive his medication on April 24, just four days before he passed away. He was given four days’ meds at a time to keep in his room and take himself, but spot checks to make sure he took his tablets did not take place as they should have.

Counsel for the family Lily Lewis probed whether the missed drugs could have increased his risk of suicide. Ms Mangan said: “Based on non-compliance, yes.”

Recommended reading:

• 'Loving' son found dead in woods while on unescorted leave from hospital

• Patient deemed 'not a risk' for unescorted leave hours before he was found dead
• Trust says lessons have been learned following death of 20-year-old patient

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The inquest heard how his family had raised concerns about his condition with hospital staff. Mum Cheryl Allan said on Monday (January 12): “He wanted to be sat in his room with the curtains down in the dark. I had raised concerns to members of staff that he was doing this.

“He looked withdrawn and had that vague look in his eyes. He didn’t want to be in that hospital.

“I just knew that he wasn’t well and we raised concerns a lot about him staying in his room and not talking to people.”

On Wednesday TEWV reassured the court that lessons had been learned since Ty’s death. The trust said it was “confident” provisions put in place would lead to improved patient care in the future.

Beverley Murphy, chief nurse at the Trust said:

“We understand how difficult a Coroner hearing can be, and our thoughts are with Ty’s family during this difficult time. We are sincerely sorry for their loss.

“We reviewed Ty’s care and have made several improvements, including the introduction of new medication practices to more robustly monitor self-administered medication.

“We will act on the inquest findings and continue to improve so that we can provide the best care possible.”

If you are in need of support you can contact the following:

- Samaritans is available, day or night, 365 days of the year. You can call them for free on 116 123, email them at jo@samaritans.org, or visit www.samaritans.org to find your nearest branch.

- If U Care Share on 0191 387 5661 or text IUCS to 85258

- SANE on 07984 967 708, Calm on 0800 58 58 58