18^th April 2017

Before HM Assistant Coroner Andrew Bridgman
Manchester South Coroner’s Court
1 Mount Tabor Street, Stockport, SK1 3AG
13.30, 18 April 2017 – expected to run for 2 weeks

An inquest hearing will start on Tuesday 18 April 2017 concerning the death of 15 year old Pippa “Pip” McManus.

Pip developed mental health difficulties from 12 years old and was diagnosed with Anorexia.  Following a serious deterioration in her physical and mental health she was admitted to The Priory Hospital Altrincham, near Manchester and detained under section 3 of the Mental Health Act on 9 September 2014.  Pip was in a severely emaciated state at the time of her admission to the Priory’s Rivendell Unit, a specialist eating disorder unit for young people up to the age of 18.  Her placement was funded by NHS England.

Pip remained at the Priory’s Rivendell Unit as a formally detained in-patient until her death on the 9 December 2015.  She had been granted home leave ahead of completion of the formal discharge process from the Priory Hospital.  Five days into her leave Pip left her home, walked to the nearby train station and died when she was struck by a train.

Key questions the inquest must now address include:
• Whether Pip received appropriate levels of mental health care and treatment during her 15 months in the Priory’s specialist unit;
• The adequacy of care and risk assessments at all stages during her admission; 
• Why a decision was taken to discharge Pip at a time when her family believed she remained extremely unwell and at high risk.

Deborah Coles, Director of INQUEST says:
“While we will not know the exact circumstances surrounding her death until the inquest concludes, the case of 15 year old Pip McManus reinforces INQUEST's serious and ongoing concerns over the lack of scrutiny and oversight of young deaths occurring in mental health settings like the Priory.  There currently remains no pre-inquest system of independent investigation into the deaths of children who die as mental health in-patients.

“We are aware of the deaths of several other children receiving mental health care in Priory hospitals.  With private providers now publicly funded to provide 47% of all in-patient Child and Adolescent Mental Health Services (4), we need to know that adequate safeguards and controls are in place.”

The family will not be issuing a statement or interviews until the conclusion of the inquest.
INQUEST has been working with the family of Pippa McManus since her death. The family is represented by INQUEST Lawyers Group members Gemma Vine and Komal Hussain of Minton Morrill Solicitors and Kirsten Sjovoll of Matrix Chambers.

ENDS

NOTES TO EDITORS
For further information, please contact: Lucy McKay on [email protected], both 020 7263 1111

1. INQUEST is aware of the following deaths of children and young people receiving in patient mental health services at Priory hospitals:
   • George Werb: 15 years, died on 28 June 2014, Priory Hospital Southampton.
   • Sara Green:17 years, died on 18/03/2014, Cheadle Royal Unit, Cheshire.
   • Francesca Wyatt: 21 years, died on 28 September 2013, Priory Hospital Roehampton.  In March 2013 HM Senior Coroner for Inner West London, Dr Fiona Wilcox, issued thisRegulation 28 report identifying her concerns about the risk of further deaths.
   • Amy El-Keria: 14 years, died on 13/11/2012, Ticehurst House, Hastings.  In June 2016 an inquest jury returned a finding of neglect concerning the Priory’s care and treatment.  An HSE criminal investigation was launched following conclusion of the inquest.

Media reports with further information on these deaths include this article in the Guardian.

2. 
   INQUEST has ongoing concerns about the lack of oversight and scrutiny over deaths in mental health settings. There is no single body responsible for recording the deaths of children who die as mental health in-patients, meaning we simply do not know how many children have died in these settings.
3. There is no pre-inquest system of independent investigation into the deaths of children who die as mental health in-patients, such as those done by the Prison or Probation Ombudsman or IPCC, something which INQUEST have repeatedly called for.
4. Approximately 47% of all in-patient child and adolescent mental health services are now provided by private providers, including the Priory (Source: Parliamentary question, Department of Health, Dec 2015). This statistic was provided by the then Minister of State for Community and Social Care in 2015. The number may well be higher now.
5. The Care Quality Commission’s recently published a report the way NHS trusts review and investigate the deaths of patients in England is available here.

Please refer to INQUEST the organisation in all capital letters in order to distinguish it from the legal hearing.