Prevention of Future Deaths reports · 2013
Regulation 28 report to prevent future deaths, reference 2013-0315, written 26 Nov 2013. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 26 Nov 2013 |
|---|---|
| Reference | 2013-0315 |
| Deceased | Alan Stanfield Browning |
| Coroner | Simon Fox |
| Coroner area | Avon |
| Category | Alcohol, drug and medication related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
Text recovered by OCR from a scanned PDF. OCR is imperfect: check anything you rely on against the source PDF. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1)
NOTE: This form is to be used after an inquest.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
Somewhere House
68 Berrow Road
Burnham-on-Sea
TA8 2EZ
4 | CORONER
| am Simon Fox, Assistant Coroner, for the area of Avon.
2 | CORONER'S LEGAL POWERS
| make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009
and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.
[HYPERLINKS]
3 | INVESTIGATION and INQUEST
On 31st August 2012 an investigation commenced into the death of Alan Stanfield
BROWNING, Aged 43. The investigation concluded at the end of the inquest on
Tuesday 26th November 2013. The cause of death was 1a) Multiple Injuries and the
conclusion of the inquest was Suicide
4 | CIRCUMSTANCES OF THE DEATH
Mr. Browning was discharged from Somewhere House on 40" august 2012 after
treatment for alcohol and drug abuse. CCTV showed him jumping from Clifton
Suspension Bridge on 16" August 2012.
5 | CORONER’S CONCERNS
LeyAweeSee eee
During the course of the inquest the evidence revealed matters giving rise to concern. In
my opinion there is a risk that future deaths will occur unless action is taken. In the
circumstances it is my statutory duty to report to you.
The MATTERS OF CONCERN are as follows. -
1. Mr. Browning was discharged from Somewhere House without his family being
informed of arrangements for his accommodation.
2. He was also discharged on a Friday, as a result of which there was little time to
ensure accommodation was provided, and no proper accommodation was found
for him.
3. The evidence was unclear as to whether Somewhere House routinely ensured
family involvement before discharge, even where a client consented to this.
4. The evidence established the importance of discharge and accommodation
arrangements in vulnerable clients such as Mr. Browning
6 | ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and | believe you
{AND/OR your organisation] have the power to take such action.
7 | YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report,
namely by 25th January 2014. i, the Coroner, may extend the period.
Your response must contain details of action taken or proposed to be taken, setting out
the timetable for action. Otherwise you must explain why no action is proposed.
COPIES and PUBLICATION
| have sent a copy of my report to the Chief Coroner and to the following Interested
Persons [Family and Avon & Wiltshire Mental Health NHS Trust.
lam also under a duty to send the Chief Coroner a copy of your response.
The Chief Coroner may publish either or both in a complete or redacted or summary
form. He may send a copy of this report to any person who he believes may find it useful
or of interest. You may make representations to me, the coroner, at the time of your
response, about the release or the publication of your response by the Chief Coroner.
26/11/13
[Dr. S. Fox, Assistant Coroner]
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