Draft:Charlie Millers

Born female, Millers came out as a transgender boy at the age of 12. He was diagnosed with ADHD and autism and had experienced behavioural issues since being in primary school, before attending Lostock High School. His family described him as a talented artist who loved Morris dancing, football, and animals. Millers was subjected to severe bullying at school related to his gender identity, which contributed to his declining mental health. He once threatened to jump from the roof of his school. He also experienced sexual abuse for several years.

Millers struggled with poor mental health from childhood, with his condition worsening in his teenage years. He received support from Trafford Council's children's services due to his history of self-harm and suicide attempts. Millers was admitted to the Junction 17 mental health ward at Prestwich Hospital on three separate occasions in the months before his death. The last of these admissions was for six weeks, beginning on 20 October 2020. During this time, his self-harming behaviours escalated in frequency and severity.

Millers was referred to the Gender Identity Development Service (GIDS) when he was nearly 14. An inquest heard that he was due to progress to medical interventions, including hormone blockers, but his mental health and self-harming needed to stabilise before he could be placed on a treatment plan. The delays in his care and the slow pace of the process were a source of significant distress for him.

On 2 December 2020, Millers was found unresponsive in his room on the Junction 17 ward after hanging himself. He was taken to Salford Royal Hospital, where he died five days later, on 7 December 2020, from a hypoxic brain injury. He was 17 years old. Millers was the third young person to die at the hospital in less than a year.

A multi-week inquest into Millers' death began in April 2024 at Rochdale Coroners' Court. The inquest was initially delayed for over a year due to a Greater Manchester Police investigation into the circumstances of his death, which was launched after questions were raised about whether hospital records had been altered. The police investigation concluded there was insufficient evidence for criminal charges, allowing the inquest to proceed. The jury was instructed to consider whether Millers intended to end his life.

In a narrative conclusion, the jury found that there were multi-agency failings leading up to his death and that he did not intend to die. The inquest identified multiple failures in his care, including inadequate communication between Trafford Children’s Services and mental health services, the failure to provide practical support to his mother and siblings, and inconsistent and incomplete record-keeping by staff. The jury also found that the patient observation system was flawed and inconsistent, and concluded that the decision not to place him on one-to-one observations probably contributed to his death.

• Alice Litman
• Cass Review
• Prevention of future deaths report