Devastated family's fears as medical notes from hours before daughter's fatal incident on NHS ward 'go missing'

A family has shared their heartbreak after a ‘kind and loving daughter’ died after staying at a Greater Manchester mental health unit.

Cerys Lupton-Jones was just 22 when she died following a stay of around six months in Park House, a mental health unit based at North Manchester General Hospital. The unit is operated by Greater Manchester Mental Health NHS Trust.

Cerys was found ‘unconscious’ on Elm ward on the afternoon of May 13, 2022, according to her family. She died five days later.

Cerys was supposed to be observed every 15 minutes on a one-to-one basis during the period of time leading up to when she was discovered unconscious, the Manchester Evening News understands. However, notes supposed to be completed by mental health staff covering the 15-minute observations in the two hours immediately prior to the ‘fatal event’ are now ‘missing’, Manchester Coroner's Court heard on October 11, 2023.

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The 15-minute observation plan had been instigated after Cerys had experienced multiple incidents involving ligatures on the ward, her family has said. But sheets of handwritten notes about the 15-minute observations that were meant to take place from 1pm to 3pm on May 13 are ‘missing’, a pre-inquest review into Cerys’ death was told.

Cerys was involved in a ‘ligature event’ the previous day, May 12, and another at around 2.30pm on May 13, the court heard. She was then found unconscious after another incident involving a ligature half an hour later, at around 3pm.

The 3pm ‘ligature