An inquest ruled that a man was unlawfully killed due to failings by two nurses who sent him home after gluing his head shut
A man was unlawfully killed because of failings by two nurses at Whiston Hospital after he was fatally injured in an assault by his girlfriend’s ex-husband. Matthew Charnock died in hospital three days after he was smashed over the head with a wheel brace by Steven Cotterill who came home early from work and found the 35-year-old visiting his former partner Natasha.
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. Mr Charnock, described by his parents Jean and Terry as “a cheeky chappy who loved a prank”, was found unresponsive the following day and was taken back to hospital.
Previous reports in the ECHO detailed how Mr Charnock, whose skull was fractured in the attack, died three days later 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.
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Although Cotterill was sentenced to seven years for manslaughter following the attack on March 13 2016, Mr Charnock’s parents have spent eight years pushing for the failings at the 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.
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In a record of inquest provided to the ECHO, 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 told the ECHO that 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 told the ECHO 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, following the advice of Daily Mail journalist Liz Hull, who has remained in contact with the family for a number of years, the Charnocks 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, of Sale in Greater Manchester, were told that the coroner had determined their son’s death was contributed to by neglect.
Mr Charnock’s mum Jean told the ECHO this week: “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.
The ECHO previously reported that Mr Charnock had started dating Mrs Cotterill, then 34, in the weeks before the attack. Jealous Cotterill, then 39, who the court heard knew about the relationship, sent unanswered messages to her seeking reassurance that she was no longer seeing Mr Charnock.
After Cotterill left work at Fiddler’s Ferry and arrived back at his Widnes home that he still shared with Mrs Cotterill, he chased Mr Charnock before attacking him with the wheel brace. The prosecuting barrister in the case told the trial the wheel brace was a “fearsome” weapon and Cotterill intended “really serious harm”.
His Honour Judge Alan Conrad KC, who presided over the case, said: “I find that this was a case where it was not necessary to use force and that the blows you struck were in anger at seeing Matthew Charnock.” In a victim impact statement read at Cotterill’s sentencing at Liverpool Crown Court, Mr Charnock’s dad Terry said his son’s reputation was “besmirched” and they had to endure a “character assassination”.
He told the court: “He suffered beyond comprehension as a result of a mindless assault. He did not have an angry bone in his body. Matthew was the love of our lives. Every second is now a lifetime of heartache for us.”
Mrs Charnock said her son, an accountant who also did voluntary work, was “a cheeky chappy who loved fun and worked hard”. She told the ECHO: “Following his death, Whiston Hospital put measures in place, so Matthew has helped make changes at that hospital.”
A spokesperson for Mersey and West Lancashire Teaching Hospitals NHS Trust, which Whiston Hospital falls under, 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.”
