Charlie Millers' mum has vowed to continue her 'fight for justice' - and has called for a public inquiry into an NHS trust - after an inquest jury concluded he did not intend to take his own life and identified failings in his care.
They also said he should have been the subject of a 'care protection plan'. Jurors said GMMH's observation system, where staff checked on Charlie during his stays on wards including at the time he was fatally injured, was 'not robust enough' and was undertaken 'inconsistently at best'. "The inquest heard there was insufficient evidence for them to do a thorough investigation. I believe they should look at it again.
Samantha added: "It is the same story over and over again. I think the orders issued by coroners - to prevent further deaths - are not changing anything. I have no doubt the coroner in Charlie's case will put everything into her report. But I'm fearful of it happening again. Charlie's medical cause of death was given as 'hypoxic brain injury'. The jury said ADHD, 'mixed conduct' and autism spectrum disorders - and an emerging emotionally unstable personality disorder - were 'background features' to his cause of death. Self-harm was a symptom of his mental health diagnoses, jurors added.
Charlie struggled with his mental health from around the age of five. Things worsened through his teenage years. This manifested itself in serious self harm; and thoughts of wanting to die and hearing voices, including a voice he named 'X', which told him to harm his family or himself.
Source: Law Daily Report (lawdailyreport.net)
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