Prevention of Future Deaths reports · 2013
Regulation 28 report to prevent future deaths, reference 2013-0374, written 17 Dec 2013. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 17 Dec 2013 |
|---|---|
| Reference | 2013-0374 |
| Deceased | Sean Seabourne |
| Coroner | Geraint Williams |
| Coroner area | Worcestershire |
| Category | Mental Health related deaths |
| Organisation named | Herefordshire and Worcestershire Health and Care NHS Trust |
| 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.
ANNEX A
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:
4. Worcestershire Health and Care NHS Trust
2,
3.
1 | CORONER
| am Geraint Urias Williams, Senior Coroner, for the coroner area of Worcestershire
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.
3 | INVESTIGATION and INQUEST
On 5" September 2013 | commenced an investigation into the death of Sean
Christopher SEABOURNE then aged 44.
The investigation concluded at the end of the inquest on 12 December 2013.
The conclusion of the inquest was Mr Seabourne killed himself the medical cause of
death being hanging .
4 | CIRCUMSTANCES OF THE DEATH
Mr Seabourne was suffering with recurrent periods of depression and anxiety and in
August 2013 sought assistance from his GP and from your service.
He was referred initially by the GP to the Community Mental Health Team who passed
him on the Assessment Team with a view to a formal assessment , crisis support and
thereafter either an informal admission to hospital or work from the Home Treatment
Team.
On the 1st September 2013 (after contact with the Crisis Support Team) he hanged
himself at his place of work at Church Green in Redditch.
5 | CORONER’S CONCERNS
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) The Community Mental Health Team assessed Mr Seabourne as being a man with a
definite plan to kill himself which the sought to hide from professionals. The CMHT
referred Mr Seabourne on an urgent basis to the Assessment Team making it plain that
he was making positive plans and that he should be seen on the same day with a view
to a formal assessment to consider a voluntary admission to hospital or Crisis Support. It
was stressed by CMHT that Mr Seabourne needed to be seen face to face because of
his ability to “dissemble” and thus hide his plans to kill himself. There was no written
confirmation of the CMHT duty workers view and requests.
(2) The Assessment Team denied being asked to assess Mr Seabourne and although
the team member acknowledged that he had been made aware that Mr Seabourne was
deliberately concealing settled plans to kill himself he took the view that the matter was
not urgent and contends that he was not asked to perform an assessment. The team
member concerned indicated that in his judgement a request for crisis support does not
require an assessment of the patient.
(3) It was clear from the evidence that there was a lack of effective communication
between the separate teams which comprise of Menta! Health Services within the
County with the Team Manager of the Assessment Team being unaware of (upon the
end of the 72 hour involvement with Mr Seabourne on the part of his team) whether the
CMHT would become automatically involved with onward work with Home Treatment
Team.
It appears that there are systemic failings in terms of communication and understanding
of roles and responsibilities in respect of the patient whom everyone acknowledged was
at high risk and with settled plans to kill himself.
It appears from the evidence that a lack of formal communication where all details are
past from team to team led to a situation where those having contact with Mr Seabourne
were unaware of the real risk that he might kill himself.
Had all of the concerns of the GP and original psychiatric nurse who referred Mr
Seabourne been formally documented and disseminated to each of the new teams then
itis likely that he would have been seen face to face and a formal assessment
considering whether he should have been admitted to hospital would have been
undertaken. This may well have changed the outcome in this case.
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and | believe you have
the power to take such action: .
1. To review the lines of communication between teams.
2. Toconsider whether referral between teams should be made or confirmed in
writing.
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report,
namely by 7 February 2014 |, 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
| am 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.
Signed
GU Williams 17th day of December 2013
H M Senior Coroner
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