Neglectful nurses glued attack victim's head and sent him home - then he died

A man died after neglect by two nurses who glued his head and sent him home after he was brutally attacked by his girlfriend's ex-husband, an inquest found.

Matthew Charnock, from Manchester, died at Salford Royal Hospital three days after he was smashed over the head with a wheel brace in 2016 by Steven Cotterill, who found the 35-year-old visiting his former partner in Widnes.

Accountant Mr Charnock was rushed to Whiston Hospital after the vicious assault but despite appearing dazed and bleeding heavily, he was sent home after nurses wrongly recorded him as being alert and only slightly confused.

He was found unresponsive the following day and taken to Salford Royal where it was discovered that his skull had been fractured in the attack and he died having suffered complications due to sepsis.

Cotterill, who argued he acted in self-defence, was cleared of murder, but found guilty of manslaughter after a three-week trial. Although he was sentenced to seven years for manslaughter, Mr Charnock's parents Jean and Terry, from Sale, Trafford, have spent eight years pushing for the failings at Whiston Hospital to be recognised.

At an inquest held at Cheshire Coroners' Court earlier this month, senior coroner Jacqueline Devonish ruled Mr Charnock was unlawfully killed due to neglect by two members of hospital staff - triage nurse Stephanie Keelan and nurse practitioner Paul O'Brien.

In a record of inquest, reported the Manchester Evening News, Ms Devonish said: "On March 13 2016 at around 10.40pm, 35-year-old Matthew Charnock was assaulted by means of having been struck over the head with a metal bar. He was transported by ambulance to Whiston Hospital at 11.33pm with confusion, accompanied by the police. Both the paramedic and police officer handed over the history of the injury and expressed concerns about his confusion to the hospital receptionist and triage nurse.

"Mr Charnock was quickly triaged by the nurse and then to the emergency nurse practitioner (ENP) for review. Record keeping and observations were inadequate such that the nurse wrongly recorded him as being alert and also slightly confused. The ENP did not review the paramedic patient record form nor take into account the previous history nor refer Mr Charnock to a doctor, nor request a CT scan in accordance with trust policy before discharging Mr Charnock having glued his head wound.

"On March 15, Mr Charnock was found unresponsive and an ambulance transported him to Salford Hospital where a CT scan revealed a significant skull fracture and infection. He was taken directly to theatre but his condition was unsurvivable and he therefore sadly passed away at 2.20am on March 16, 2016."

Mr Charnock's mum Jean said Ms Keelan, who did not give evidence at the inquest, left Whiston Hospital soon after the incident to work at a local walk-in centre, while Mr O'Brien said he believed the injuries to be superficial during his evidence. The nurses were never charged with gross negligence by the Crown Prosecution Service (CPS) as their actions could not be classed as 'deliberate criminality'.

Mrs Charnock said that due to the CPS's bar being so high, following the criminal proceedings of Cotterill they didn't know how they would be able to have the events at the hospital investigated. However, they pushed for the inquest to be reopened.

An investigation was launched in February before the inquest was officially reopened on March 6. But it was only after the culmination of a two-day inquest on September 3 and 4 that Mr Charnock's parents were told that the coroner had determined their son's death was contributed to by neglect.

Mr Charnock's mum Jean said: "It should never have taken eight years to get to this point. There's been plenty of grieving for Matthew. It's still very hard now but your inner self has to take over. You have to get justice for your son.

"You almost have to treat it like a job, reading and re-reading reports that aren't nice. During the inquest we were hearing doctor's reports that gave blow by blow descriptions of what happened, which was really tough. We didn't realise until the inquest that the triage nurse was also culpable."

However, despite this, the Charnocks hope for more "face-to-face accountability" in the future. Mrs Charnock said that Ms Keelan should have given evidence at the inquest and should not have been able to move from Whiston Hospital to another NHS service without accountability for what happened. She said she hopes her son's case can bring about change in the future.

"Following his death, Whiston Hospital put measures in place, so Matthew has helped make changes at that hospital," she said.

A spokesperson for Mersey and West Lancashire Teaching Hospitals NHS Trust said: "We would like to express our heartfelt condolences to Matthew’s family for their loss and to once again offer our sincere apologies for the failings in his care at the time. Following Matthew's death a thorough investigation was carried out, the findings of which were shared with Matthew's family. Lessons have been learned and robust action taken to ensure a tragic incident like this does not happen again."