Before HM Senior Coroner for North Manchester, Joanne Kearsley Rochdale Coroners Court 19 October 2020 (part heard and then adjourned till 5 January 2021) concluded 8 January 2021

The inquest has concluded into the death of Matthew Copestick on 8 January 2019, with the coroner finding his cause of death was a sudden and unexpected death in alcohol dependency. The coroner was unequivocal that when Matt was taken to Fairfield A&E four days prior to his death, he should have been admitted for inpatient detoxification. The coroner concluded that this did not happen due to poor communication between staff and a lack of understanding of the referral process.

The coroner identified further failings in Matthew’s care, including that:

• No post detox care plan existed for 2018.
• There were failures in inter-agency communications and Turning Point, the drug and alcohol service managing the detoxification budget in Rochdale, missed opportunities including key meetings to plan for Matt’s detoxification.
• Agencies could have acted far earlier given knowledge that they had on 5 November 2018 which they did not communicate to Matt’s family or act on until 13 December 2018.
• Following on from 13 December 2018, there was no plan for support over the challenging Christmas period and no planning for inpatient detoxification, which should have been undertaken by Turning Point.

Matt was from Rochdale. He had a diagnosis of autism and had a high level of care needs result, which Rochdale Borough Council (RBC) were responsible for coordinating. Evidence at the inquest showed Matt to be a friendly, funny and kind hearted 21-year-old man, who was beloved by his family and everyone who came into contact with him. He loved football, was an ardent supporter of Rochdale FC and always dressed in black.

The inquest heard that Matt became alcohol dependent during the difficult transition years of young adulthood, a transition which presented many more challenges for Matt than it would have for somebody without his diagnosis. He was determined to address his dependence and was fully engaged with a number of services at the time of his death. 

From the summer of 2018, the inquest was told that Matt needed an urgent alcohol detoxification and that his alcohol dependence had become life threatening. On 4 January 2019 Matt was found unwell at home by his carers and was taken to Fairfield A&E. Evidence was heard that he consented to, and was excited to enter detoxification and was told he would be able to do so.

Matthew was unable to gain access to a detoxification programme, despite being referred in September 2018 to Turning Point, the drug and alcohol service managing the detoxification budget in Rochdale. The inquest heard evidence about the lack of understanding by professionals of the pathway for detoxification and the failure to plan for Matt’s admission. That even though everyone, including all the health professionals wanted Matt to go into a detox that day, a route was not found to achieve this.

The inquest heard evidence that:

• The detoxification pathway was not adapted to suit Matt’s needs due to his autism.
• Contrary to NICE guidelines, there was not an adequate training programme for Turning Point staff caring for those with an autism or learning disability diagnosis.
• There were inadequate attempts to ensure specialist input into Matt’s care.
• There was inadequate communication and engagement with Matt’s family by Turning Point.
• It was clear to professionals from at least November 2018 that Matt would be unlikely to access detoxification under the approach which was being taken. Despite this, there was no alternative specialist plan put in place.

Following her conclusions, the coroner acknowledged the role of Matthew’s family in battling for his corner at every stage to ensure he received appropriate care and recognised the impact on the family of the delays in the inquest process.

Helen McHale and Lee Copestick, Matthew’s parents, said: 

Having sat through all the evidence it remains clear to us that Matthew did not need to die. It is clear that Matt was let down and that better communication, an understanding of how Matts autism impacted on him, and listening to us more, would have resulted in a different outcome. Days before his death Matt said ‘Mum I want my detox before I die’. This had a powerful impact then, but it haunts us now.

We are privileged to have had this inquest, to learn much more, have our questions answered, get the chance to take the first step in holding some people and organisations to account. We were shocked to receive admissions and documents nearly two years after Matt’s death, and the coroner was astounded by Turning Point’s approach to disclosure. The admissions ran in the face of the previous constant denial. Grateful though we are for these opportunities the inquest system is not loaded in favour of families who are often left alone to navigate complex legal processes. Many families are only able to be legally represented at court if they can afford to pay themselves. In our case this is in contrast to the five other agencies who all have legal teams funded by the state. It has been a long hard battle to get this far.

Emily Comer of Broudie Jackson Canter, who represents Matthew’s family, said: 

Matt’s family have fought tirelessly throughout this incredibly difficult process to gain answers from the parties involved. With the coroner’s conclusions, we hope that lessons will be learnt across organisations to avoid such avoidable tragedy in the future. 

Selen Cavcav, Senior Caseworker at INQUEST said: 

The failures in this case would not have come to light without the family’s tenacity and their drive to prevent other young people like Matthew dying. There is a systemic issue in relation to the delivery of life saving services for vulnerable people with autism. One size does not fit all. Ignorance, lack of training and lack of a person centred approach continues to end in so many deaths. Failures identified in this case must be addressed at a national level.