Charlotte Parry’s death contributed to by neglect on part of Greater Manchester Mental Health trust, inquest jury finds

11 April 2025

The jury’s findings brought an end to an emotional two-week inquest at Manchester Coroner’s Court (pictured). Credit: Alex Blair / Garden Court North Chambers.

Earlier today (11 April), an inquest jury found that neglect on the part of Greater Manchester Mental Health (GMMH) NHS Foundation contributed to the tragic death of Charlotte Parry on 6 February, 2022.

Charlotte was detained under the Mental Health Act 1983 on the Bronte Ward of Wythenshawe Hospital due to her high risk to self and diagnoses of Emotionally Unstable Personality Disorder, Obsessive Compulsive Disorder and Generalised Anxiety Disorder.

The jury made numerous critical findings in relation to the care provided to Charlotte during her time under GMMH care, including in relation to her observation levels, the return of items used to ligature, delays in applications for funding for specialist treatment and ward systems for managing ligature risk, finding that these caused or contributed to Charlotte’s death.

The jury also made a number of critical findings in relation to the Trust as a whole, including that the systems in the Trust for managing ligature risk were not adequate, and that this possibly caused or contributed to Charlotte’s death. They further found that there were significant and systematic failures in the Trust and incompetence at a senior leadership level.

The jury’s conclusion brought an end to an emotional two-week inquest at Manchester Coroner’s Court.

Carol Parry, Charlotte’s mother, said in a statement: “We as a family are absolutely devastated. For the jury to conclude neglect by GMMH contributed to Charlotte’s tragic death makes this even more unbearable. To date, we have not received any sort of apology for their significant and systematic failures including numerous critical findings in relation to Charlotte’s care.

We would like to thank HM Coroner Mr Appleton, the jury and our legal team (Kelly Darlington of Farleys Solicitors and Lily Lewis of Garden Court North Chambers) for their professionalism and kindness. We are pleased that Professor Shanley and the CQC [Care Quality Commission] are closely monitoring GMMH’s practices and hope that changes continue to be made to protect other patients within their care.

We as a family are not making any further comment at this time as we continue to navigate life without our beautiful Charlotte.”

Throughout the inquest, Garden Court North’s Lily Lewis rigorously questioned dozens of Trust witnesses called to give evidence on the circumstances surrounding Charlotte’s death.

Lily and Kelly Darlington of Farleys Solicitors represented Charlotte’s family.

Charlotte Sophia Parry (pictured). Credit: Farleys Solicitors.

Additional media

The Mill – How a Manchester mental health ward neglected a suicidal patient

Manchester Evening News – The ‘gross failures’ that led to death of ‘beautiful’ Charlotte

Farleys – Inquest into the death of Charlotte Parry concludes with Jury finding Neglect of GMMH

For further information, please contact Alex Blair, Communications Manager at Garden Court North Chambers: ablair@gcnchambers.co.uk