Last month the inquest into the death of Matthew Copestick concluded, two years to the day that he died, on 8 January 2019. I spoke with Matthew’s mum Helen and had the pleasure of reading the eulogy from his funeral. I wanted to share a little about Matthew with you before getting into his inquest.

Matthew was a summer baby, born in August 1997, pictured here as a teenager on a family holiday, Matthew always loved water.

Matthew was 21 when he died, at his home in Rochdale.

‘Matt was polite, respectful, took responsibility… he loved his identification as a gentle giant… respecting people and treating people equally were central to Matt. It meant not only that he had to treat you with respect, but you had to do the same to him and he would take great offence if you didn’t.

He would never sit in the front of the car if there were older people in it, he always shook your hand when he met you and so should you’.

Matthew’s inquest heard about how he ‘was obsessive and could be rigid in his thinking’ and some of the difficulties it presented. On the flip side there are football clubs all over the country who rely on their supporter’s rigid thinking in that regard.

A Rochdale Football season ticket holder all his life, Matthew had an exceptional memory when it came to Rochdale and was able to recall the year, score and goal scorers of games long past. Matthew had an unwavering devotion to Rochdale, which when combined with his impeccable manners, meant he never left a match early:

‘You couldn’t leave a football match before the end, even when Rochdale were losing 4-0 with 4 minutes of extra time we still had to wait for the final whistle’.

Matthew had Aspergers and he liked order and structure. In his eulogy his father described in more detail:

‘Matthew had passions and obsessions, the enduring ones snooker, football, music and film. I always felt that Matthew was at peace with himself when playing snooker, it was one of those rare occasions when he actually stopped chattering.  He wouldn’t allow me to chat either, respecting the manner in which snooker should be played’.

Matthew loved music, but had little time for modern artists, instead he was a huge Elton John fan and wasn’t averse to belting out Tiny Dancer at the top of his voice, whilst playing an imaginary piano.

Matthew also liked films, and once one was a favourite, it would be watched on a permanent loop. Throughout his life the honour went to Spiderman films, Harry Potter, Lord of the Rings, Green Mile and There’s Only One Jimmy Grimble.

By the time Matthew came to be living in his own flat, with the help of Newbarn Supported Living, films had been replaced by a love of box sets, with This is England and Phoenix Nights becoming firm favourites.

Matthew loved his flat, and him and his family had a great relationship with the staff at Newbarn and Renaissance. When talking to his Mum after his inquest she told me that she’d written to the staff who supported Matthew:

‘I’ve written to them to say Matthew loved them, they were brilliant, they created that chance. I want them to take that away’.

Matthew had developed some problematic obsessions, and while he was able to reject some, BB Guns and cannabis for example, others took hold. Once an obsession had moved to an addiction, they were harder to break. Matthew underwent an inpatient detoxification programme in January 2018 regarding drug use. By August 2018 he’d managed to stop using spice, but his drinking escalated rapidly and was at an excessive level.

Helen considers that the people who came in for the most criticism from the Coroner were the two people, Peter and Caroline, who’d done more for Matthew in his life than anyone else. It sounds to me like they were prepared to bend the rules and operate a little outside of procedures, but obviously that doesn’t come out well in a Coroner’s Court. Helen reflected that:

‘Men in grey suits who said we’ve written new policy here, got it easy’.

Helen is at pains to stress that Matthew’s carers, other than Turning Point’s detox team, were brilliant.

‘They communicated with us well, lots of good practice went on for Matthew’.

Matthew was analytical. He’d analyse song lyrics and draw meaning from them. He loved analytical conversations, meaning his family knew intimately his views and thinking on lots of things, including what he wished for his funeral. They also knew what he’d like his last meal to be if he ever found himself on Death Row:

‘Jam Roly Poly and custard for pudding with a curry buffet Matthew style, poppadoms, mango chutney, red onion and yogurt sauce.  Bhajis, meat Samosa the Chicken Tikka Masala, pilau rice (small amount) didn’t really like rice and a large garlic naan bread’.

Matthew was detailed, and specific. A man of routine. He kept his head shaved and always wore black, and everything in his flat had to be black, although his family report that he allowed the walls in the lounge of his flat to be painted grey, as a concession to visitors.

His father concluded Matthew’s eulogy as follows:

‘Matthew, above all, has been a great teacher, his struggles have taught me to be less judgemental, to condemn less and understand more, every individual who is battling with mental health and addiction issues has a backstory which ought to be listened to.

For me the most powerful thing is that Matthew could draw enormous pleasure from the very simple things in life, a plate of food, a piece of music, a thought provoking film. In a world obsessed by materialism and celebrity Matthew always provided a welcome counterbalance. For that alone I know his life has not been wasted.

Goodbye Matthew, love you loads, it’s been a privilege being your dad’.

So how come Matthew is no longer with us? What happened?

Senior Coroner Joanne Kearsley found that Matthew died as a result of complications of alcohol dependency; his was a sudden and unexpected death in alcohol dependency.

In her summing up the Coroner described how as Matthew transitioned into adult services:

‘His behaviours had, understandably become more challenging as he got older as he asserted his independence. He could be difficult to control and was clearly a young man who could be very strong minded – his Father described him as someone who had the ability to give things up such as drugs or alcohol but he had to be guided to the decision and he had to think things through for himself. He was a vulnerable young man’.

Matthew became alcohol dependent during these years into young adulthood, a transition which presented many challenges to Matthew due to his autism. Matthew was adamant he wished to address his alcohol dependence and he was fully engaged with a number of services at the time he died. Helen told me how Matthew had the sense of his impending death. She reflects how in one regard Matthew’s death was unexpected, but in another they lived with the risk, everyone knew that it could happen, it was ‘intense, palpable’.

The court heard how there was no post-detox care plan in place for Matthew throughout 2018. It was clear that Matthew needed an urgent detox by the Summer. A series of failures in communication between the agencies involved in Matthew’s care, meant that a number of opportunities to help Matthew and arrange his entry to a detoxification programme were missed, with devastating consequences.

There were six interested persons, in addition to Matthew’s family: Rochdale MBC, Newbarn Supported Living, Turning Point, Greater Manchester Mental Health Trust, Northern Care Alliance Group, and Pennine Care NHS Foundation Trust, all with legal representation paid for by the State or corporate insurance schemes, at Matthew’s inquest.

The Coroner stated:

‘Despite the fact Matthew remained in Rochdale after his detoxification in January 2018, that he continued to use drugs, that his level of alcohol use had increased significantly by the August 2018 and an urgent referral had been made to Turning Point in September 2018, no MRM [Multi agency risk management meeting] was held between January 2018 and the 25th October 2018. In my opinion this was a significant missed opportunity in the care of Matthew’.

Matthew, a vulnerable young man with autism and substance abuse problems was referred to Turning Point in September 2018. Turning Point who boast on their website:

Turning Point are experts in delivering innovative integrated care in communities, specialising in substance misuse, mental health, learning disability, employment services, criminal justice, primary care and public health. 

Yet here we have a young man needing help from these specialist services and they failed to attend the multi-agency risk management meeting held on 25 October. They then failed to attend the multi-agency risk management meeting held on 9 November. They also failed to attend the multi-agency risk management meeting held on 4 December. The Coroner noted how their apologies had been noted in each of the meetings, so it’s not that they were unaware.

Matthew’s heath declined and blood tests by his GP showed evidence of abnormal liver function. An effective multi-agency risk management meeting was eventually held on 13 December, although it finished with no date fixed for the next meeting. The meeting also failed to discuss the forthcoming Christmas period, even though Matthew’s mum was clear it would be a challenge for him, due to his autism and she feared it would lead to an increase in his drinking.

The Coroner observed:

‘Mrs McHale in her evidence said that there was never a clear agreement until the 13th December that Matt needed a detoxification then on the 13th December there was an agreement but there was no idea as to how it would be delivered or accessed. She said, “I think we all thought Matt needed an urgent detox it’s hard to get across the sense of urgency and fear we all felt“.

For any parent those weeks between September and December trying to get support for her son must have been desperate and I acknowledge the input and support Mrs McHale provided during that time to all the professionals involved’.

Matthew’s parents’ fears were well founded. At this stage everyone knew Matthew was at risk, yet Turning Point still failed to make any plans for inpatient detoxification.

Helen described how Turning Point had continually denied and diminished their role in failings related to Matthew’s care. Their own internal investigation exonerated them and blamed others. A multi-disciplinary review kept to the same line. They had never apologised and never admitted anything, until the third day of the inquest when they suddenly capitulated after the Coroner persisted with questioning. In a quite remarkable move, Turning Point made a series of admissions about the opportunities that they missed in providing care to Matthew.

These included a number relating to ignorance of autism: 

• Not having adequate training in place to ensure ‘staff members were familiar with particular needs and challenges arising from working with people with autism’ 

• ‘Turning Point had not devised or implemented an effective system’ to enable their staff to access support and assistance from those with autism expertise and experience 

• Inadequate provision of resources regarding autism

• ‘Turning Point did not make adequate attempts to ensure that suitably qualified professionals’ with autism expertise worked with Matthew towards an appropriate detoxification plan.

Their communication failures and failure to adopt a ‘collaborative approach when working with other professionals and with Matthew’s family’ were also acknowledged. As were the lack of support or continuity over the Christmas period, insufficient focus to adapt pre-detoxification programmes to Matthew’s needs, and delays in making preparations for a planned residential detox. 

Quite the turn around, from nothing to see here on Day 1 to no less than nine significant admissions two days later. The legal team for Turning Point did of course invite the Coroner to hear evidence ‘of the lessons learned and the measures that have or will be introduced as a result’.

It seems like quite a leap to me, no responsibility on Day 1 to full scale mission to persuade the Coroner they don’t require a Prevention of Future Death report a few days later… personally I’ve little confidence if it took a Coroner’s scrutiny for them to see the light that they will make any required changes, but luckily for them it’s not me that they needed to persuade. 

They also played the inevitable caveat card, that despite all these admissions of their failures, they were ‘unable to admit that the matters acknowledged in (1) to (9) above caused or contributed to Matthew’s death’.

Helen describes how they were banging on the door of Turning Point, and still couldn’t get them to really engage with Matthew, and she wonders, and worries, what happens to people who don’t have support.

On 4 January 2019 Matthew was found unwell at home by his carers. He was ‘extremely disorientated, unsteady’ and also had a cut to the back of his head. His carers took him to Fairfield General Hospital Accident and Emergency Department, run by Pennine Acute Hospitals NHS Trust.

Once at A&E Matthew was seen by staff there, who worked for the Acute Trust, and he was additionally seen by an Alcohol Liaison Nurse who worked for Pennine Care NHS Trust. Contact was also made with the Chapman Barker Unit, a regional detoxification inpatient unit run by Greater Manchester Mental Health NHS Foundation Trust.

Despite all these services, or perhaps due to the inability of services to effectively work together, Matthew fell through the cracks.

Matthew was declared medically fit by the Acute Trust staff member as she believed that he would be admitted for alcohol detoxification (and needed to be medically fit to do so). This declaration was made despite Matthew not receiving the ECG that had been requested, having a pulse rate of 135 and no second set of observations ever being taken. She told the Court:

‘had the alcohol liaison nurse not have been available at the time then she would have arranged Mr Copestick’s admission to an inpatient acute medical bed by referring him to the medical team’.

The alcohol liaison nurse told the Court she understood Matthew was being brought to A&E ‘with the specific intention of trying to secure him an inpatient detoxification’. After seeing Matthew she completed a referral form for the Chapman Barker Unit and faxed it to them.

It seems to me that bureaucracy and budget codes cost Matthew his life. The Coroner made a ruling of fact, after much disputed evidence, that:

‘The Court heard evidence from number of witnesses as to the process for referring a patient to the Chapman Barker Unit. It is clear and the court is satisfied that the system in place at the time necessitated the patient to have been admitted into the acute trust for an alcohol detoxification before they would be accepted into Chapman Barker’.

This emergency admission was for up to 7 days and crucially the Acute Trust pay for an emergency admission. This is known as the RADAR Pathway.

If someone did not meet the criteria for an emergency admission, then they could still access the Chapman Barker Unit by a 14 day planned admission. This would be paid for out of Turning Point’s budget.

Given the referral was made to Turning Point in September 2018 what follows next seems unforgivable.

The staff member at the Chapman Barker Unit who received the faxed referral form for Matthew:

‘told the Court she could see it stated Matt was fit for discharge so he was not suitable for RADAR. However, she did note that he was under Turning Point so she personally contacted his worker Mr Allen.

She told the court the purpose of this contact was to advise that Matt was at Fairfield General Hospital and he was not suitable for RADAR but that there were beds available for a planned admission. She was aware that it was a Friday and that she was effectively contacting them so they could make the referral as Chapman Barker Unit did not take patients on a Saturday or Sunday’.

At this point Matthew could have been admitted, all it required was completion of the paperwork and confirmation of the budget by Turning Point. The Turning Point witness could remember speaking with the staff member at the detoxification unit, but:

‘by the end of the call he was of the understanding Matt was being admitted with a view to Turning Point potentially funding a second week as it was felt Matt required longer than a RADAR admission would allow’.

The Coroner could not reconcile the differences in recollections and no clear records of the call were kept. She found given it was a Friday afternoon and Turning Point didn’t work weekends it would not have been practicable to have completed a planned referral in the short amount of time left before the weekend.

Of course at this stage Turning Point had already known about Matthew and his need for their support for 4 months. Plenty of time to arrange a planned referral one would hope.

The Coroner ruled Matthew should never have been declared medically fit in the first place, and that there was ‘no adequate assessment’ as to whether Matthew required an inpatient admission for alcohol detoxification. She continued:

‘If there had been an adequate assessment then on balance I find Matthew would have been admitted as an inpatient to Fairfield General Hospital and would have been entirely suitable for transfer to the Chapman Barker Unit on the 4th January 2019 for an alcohol detoxification’.

Instead, devastated at being rejected, having already been given the impression his admission was going to happen, Matthew became agitated, pulled out his cannula and left the hospital incredibly distressed.

Matthew’s family and carers had contact with him over the weekend. On the Saturday he said to his Mum that he wanted to detox before he died. He was desperate, he was engaging, he was trying, but budget codes and bureaucracy got in the way.

Matthew was found collapsed in his shower the following Tuesday; his Dad had seen him earlier that day and he’d not described feeling ill, although he was despondent.

The only significant finding when the pathologist conducted Matthew’s post mortem was that Matthew’s liver was significant enlarged and fatty. The Coroner stated:

‘I acknowledge it is not easy to understand how someone dies when the only pathological finding is one of a fatty liver. It is not uncommon for this court to be presented with such cases. It is important to consider all possible medical causes of death but having ruled out seizure – there is no evidence Matthew was intoxicated at the time of his death therefore his death is not due to alcohol toxicity’.

The Court heard there was no evidence of trauma, no evidence of alcoholic ketoacidosis (a metabolic disturbance), no evidence of aspiration and no other naturally occurring disease that could explain Matthew’s death.

Matthew’s cause of death was therefore recorded as 1a) sudden and unexpected death in alcohol dependency, as a result of 2) alcoholic fatty liver disease.

The most torturous finding for Helen, Matthew’s mother, is the one that follows. The Court heard evidence about the large numbers of patients who access the Chapman Barker Unit, and who survive detox. Yet this was not enough to convince the Coroner that Matthew would have survived.

Given the lack of understanding as to how a sudden and unexpected death occurs, the Coroner ruled that she could not definitively say that admission to hospital on the 4 January would have prevented Matthew’s death four days later.

Helen described how on the Saturday morning before his death, Matthew told her ‘Mum I want to detox before I die’. Words that now haunt her. Whatever the Coroner decided, Helen is certain if Matthew had been admitted on the 4 January he would have survived.

I’ll finish with some of Helen’s words from Matthew’s eulogy:

‘I will have to learn to live with the fact that ultimately I failed Matt; that we didn’t quite get to the place where he could live in peace; but I know that Matt both loved and knew that he was loved…

Matt and I were very close, he was in my head day and night. He took me to the darkest and brightest of places…

Once when telling him I wouldn’t see him for a week as I was away he said it doesn’t matter, we are always together in our heads…

He showed me my capacity for unconditional love. I miss him already but he will always be with me’.