29 October 2021

Before HM Senior Coroner Joanne Kearsley
Rochdale Coroner’s Court
25-28 October 2021  

An inquest has concluded that the self-inflicted death of mental health inpatient, Sam Copestick, was contributed to by neglect. Sam, 24, was under the care of Pennine Care NHS Foundation Trust at Prospect Place unit in Rochdale. On 20 May 2019 he died, three days after absconding whilst on escorted leave.

The inquest also identified a number of serious failings that contributed to his death, including risk assessment, leave planning, and failing to give adequate weight to his mother’s concerns.

Sam was from Rochdale. His family say that, before becoming ill, he was highly intelligent, good at every sport going, and people loved him. However, he was ‘a bit lost’ and Sam’s mental health began to show signs of deterioration in his teens, and significantly deteriorated after he returned from his first year at university.

Despite being in the long term care of mental health services, Sam’s health was showing little sign of improvement. The situation became worse after the sudden death of his younger brother, Matthew Copestick, in January 2019.

Sam had been at the Prospect Place unit for almost two years, since June 2017, following a seven month stay in Pennine care’s psychiatric intensive care unit. He was admitted there after throwing himself under a train, just nine days after being released from another mental health unit in Birch Hill hospital.

Sam’s care plan allowed for him to take escorted leave from Prospect Place, if accompanied by two members of staff, one of whom had to be male. In recent weeks he had refused to go out, finding it too distressing. His mother had been in contact with the mental health unit twice that week to inform them Sam’s health was getting worse.

On the day he died, Sam requested leave seemingly out of the blue. Leave was granted and he went out with only one member of staff, a female nursing assistant. She had no phone with her. Sam ultimately absconded and went on to die from self-inflicted injuries. 

During the course of the inquest, the Trust apologised to the family and accepted numerous failures including:

  • There was an absence of a risk management plan.
  • There should have been two members of staff escorting him.
  • There was a failure to liaise with Sam’s mother, despite her raising concerns.
  • The staff member who did escort Sam should have had a phone or radio, in case he absconded.

The inquest also heard evidence that in 2018, Sam’s mother issued a complaint about the care Sam was receiving at the unit. This was investigated and recommendations for improvements were made. However, the inquest heard that they were not put into effect.

The inquest concluded finding Sam’s death was a result of ‘injuries sustained following self-suspension from a ligature whilst suffering delusions due to paranoid schizophrenia’, contributed to by neglect.

The jury also concluded that Sam should not have been allowed leave, given the concerns of his mother, the last care planning meeting, and taking into account the last date he utilised leave. These failures contributed to his death.

The jury also identified a number of other failings which contributed to Sam’s death, including:

  • Failure to implement lessons of previous complaints by Sam’s parents regarding under estimation of risk.
  • Failure to give adequate weight to Sam’s mother’s concerns regarding his mental health following his brother’s death.
  • Failure to check the leave form which instructed two staff members to escort Sam.
  • Failures around planning and risk assessment prior to the leave, including failures to complete and countersign the required risk assessment plan, insufficient information on the leave form, and inadequate signing of the leave description sheet.

As well as these, the jury found other failures possibly contributed to his death. These included the failure to ensure staff escorting Sam took a mobile phone or radio, and a failure to pass on information at handover about the deterioration in Sam’s health.

Helen McHale, Sam’s mother, said: “Looking after people who are mentally ill is challenging, requires care, patience, skill, and sometimes things go wrong. The continued nature of these failings, however, is far deeper and longer lasting than simple mistakes.

Trying to get Sam’s distress and risk accepted was a constant battle. I know from talking to other carers and hearing other stories that these mistakes are repeated elsewhere. I truly hope these findings improve things for them. Given the continued inability to deliver some fairly simple changes, I have little confidence they will, but want to help in any way I can. 

I cannot thank enough the jury, coroner, family, friends, colleagues, our solicitor, and INQUEST, for all who played a crucial role in getting to this point. It would not have been possible without them.”

Lee Copestick, Sam’s father, said: “In the last two and a half years of Sam’s life I slept a little easier believing he was in a safe place. Since Sam’s passing, I have been angry and deeply sad realising that was not the case. These feelings remain now that the court too has concluded that Sam’s death was preventable. I hope that Pennine Care go away and make big changes to ensure that no one ever has to endure what we have been through.” 

Ruth Bundey from Harrison Bundey Solicitors, who represent the family, said: “It is beyond belief that senior Pennine staff ignored crucially informative and courteous emails, as well as calls, from Sam’s mother Helen, revealing her son’s increasing distress that if he went out on leave he would be killed. This followed two sets of admissions in the previous year that the Trust had not sufficiently listened to the family’s experiences. This devastating lack of respect ultimately led to Sam’s death.”

Lucy McKay, spokesperson for INQUEST, said: “It is clear that Sam’s family fought for him to receive the care he needed, right to the end. Despite their tireless efforts, Pennine Care NHS Foundation Trust neglected both Sam and his family. At INQUEST we see that mental health services all too often overlook the invaluable insights of families and fail to effectively manage risk and plan for patients taking leave. We must now see action, not just in this area, but nationally to ensure these repeated failures do not continue.”


For further information, interview requests and photos, please contact Lucy McKay on [email protected] or 020 7263 1111.

Sam’s family are represented by INQUEST Lawyers Group member Ruth Bundey from Harrison Bundey Solicitors.

The family are supported by INQUEST caseworker Selen Cavcav.  Other Interested persons represented are Pennine Care NHS Foundation Trust. 

Journalists should refer to the Samaritans Media Guidelines for reporting suicide and self-harm and guidance for reporting on inquests.

Matthew Copestick, Sam’s brother, also died whilst under the care of local services in Rochdale. There were multi-agency failings relating to care for drug and alcohol dependency. Matthew had autism and evidence was heard that care was not adapted to suit Matt’s needs. See the media release on the inquest conclusions regarding Matthew’s death.