Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0047, written 30 Jan 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 30 Jan 2014 |
|---|---|
| Reference | 2014-0047 |
| Deceased | Tallulah Wilson |
| Coroner | Mary Hassell |
| Coroner area | Inner North London |
| Category | Other related deaths |
| Organisation named | Tavistock and Portman NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Regulation 28: Prevention of Future Deaths report
Tallulah Mary Scarlett WILSON (died 14.10.12)
THIS REPORT IS BEING SENT TO:
1. The Right Honourable Jeremy Hunt MP
Secretary of State for Health
Department of Health
Richmond House
79 Whitehall
London SW1A 2NS
1
CORONER
I am: Coroner ME Hassell
Senior Coroner
Inner North London
St Pancras Coroner’s Court
Camley Street
London N1C 4PP
2
CORONER’S LEGAL POWERS
I make this report under the Coroners and Justice Act 2009,
paragraph 7, Schedule 5, and
The Coroners (Investigations) Regulations 2013,
regulations 28 and 29.
3
INVESTIGATION and INQUEST
On 18 October 2012, one of the assistant coroners for Inner North
London commenced an investigation into the death of Tallulah Wilson, a
fifteen year old schoolgirl.
I concluded the investigation at the end of the inquest on 22 January
2014. The jury made a narrative determination, finding that Tallulah
jumped in front of a train, taking her own life.
I attach to this report a copy of that narrative.
4
CIRCUMSTANCES OF THE DEATH
1
The jury found that, as a result of Tallulah’s dissatisfaction with her
friendship group, she created an online persona.
She posted about self harm and suicide. She included photographs that
she said were of herself following cutting.
Her consultant psychiatrist gave evidence that, with hindsight, it seems
that when her Tumblr account was deleted (following her mother’s
discovery of the damaging nature of her posts), Tallulah may have felt
herself to be in some way deleted. Thousands of people had read her
posts and she had gained great satisfaction from that. So on the one
hand, her internet use may have had a negative impact; and yet on the
other hand, preventing her internet use may have had a negative impact.
The jury included the following in the narrative determination.
“This case has highlighted the importance of online life for young people.
We all have a responsibility to gain a better understanding of this, which
needs to be achieved through appropriate dialogue. This is a particular
challenge for health professionals and educators.”
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.
Although Tallulah was treated by a number of healthcare professionals,
and her mother was extremely concerned about her wellbeing, no person
who gave evidence felt that, at the time they were looking after Tallulah,
they had a good enough understanding of the evolving way that the
internet is used by young people, most particularly in terms of the online
life that is quite separate from, but sometimes seems to be used to try to
validate, the rest of life.
Research; the development of improved clinical practice at a national
level, details of which are then disseminated by national training; and risk
assessment refinement, all seem to be key.
Digital lives basic training and audit is already available, but is not part of
standard induction training to raise awareness for all in psychiatric and
psychological fields, let alone for all doctors.
2
I heard at inquest that the Department of Health has taken the lead
nationally on youth suicide prevention, commissioning research exploring
the use of the internet and trying to understand the role of social media in
youth suicides. It is for this reason that I direct this report to you.
6
ACTION SHOULD BE TAKEN
In my opinion, action should be taken to prevent future deaths and I
believe that the Department of Health has 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 31 March 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.
8
COPIES and PUBLICATION
I have sent a copy of my report to the following.
HHJ Peter Thornton QC, the Chief Coroner of England & Wales;
Ms Sarah Wilson, Tallulah’s mother;
Dr Caroline McKenna, associate medical director,
Tavistock and Portman NHS Foundation Trust;
Professor Sir Bruce Keogh, national medical director,
NHS England;
Professor Dame Sally Davies, Chief Medical Officer for England;
Dr Maggie Atkinson, Children’s Commissioner for England;
Professor Sue Bailey, president,
Royal College of Psychiatrists;
Dr Richard Graham, consultant adolescent psychiatrist,
technology addiction lead, Tavistock Clinic;
UK Council for Child Internet Safety (UKCCIS).
I 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
interest. You may make
it useful or of
representations to me, the Senior Coroner, at the time of your response,
find
3
about the release or the publication of your response by the Chief
Coroner.
9
DATE SIGNED BY SENIOR CORONER
30.01.14
4
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
| | Department of Health POC1_ 839561 Mary Hassell Senior Coroner - inner North London district St Pancras Coroner's Court Camley Street LONDON NIC 4PP Dev Ms. thasell From the Rt Hon Jeremy Hunt MP Secretary of State for Health Richmond House 79 Whitehall London SIVIA 2NS Tel: 020 7210 3000 Mb-sofs@dh.gsi.gov.uk 31 MAR 201% Thank you for your letter of 30 January about the inquest into the death of 15 year old Tallulah Wilson who jumped in front of a train, taking her own life. In summarising your findings, you raised concerns about improved clinical practice and training of healthcare professionals. You noted that no person who gave evidence felt that, at the time they were caring for Tallulah, the health professionals involved had a good enough understanding of the evolving way that the internet is used by young people. I recognise the increasing importance of the role of media and in particular social media in the lives of young people. The first annual report on England’s cross- government suicide prevention strategy, Preventing Suicide in England: One Year On was published on 17 January and noted that the Policy Research Programme is investing £1.5 million into six projects, one of which will explore the use of the internet in relation to suicidal behaviour and identifying priorities for prevention. This study is being undertaken by researchers at the University of Bristol, in partnership with Samaritans and Papyrus. The research started in October 2013, and is due to complete in March 2016. The aim of the research is to: a) provide detailed empirical evidence about use of the Internet for suicide-related purposes and how this beneficially and/ or detrimentally influences suicidal feelings and behaviour; b) use these findings to inform advice to policy makers, clinicians, voluntary sector organisations, and the Internet Industry; and identify potential interventions to be developed and future programmes of work with these groups. The Royal College of Psychiatrists As the body responsible for education, training, setting and raising standards in psychiatry, the College is heavily involved in both development of the government’s suicide prevention strategy, and research to support it. I have invited them to comment on the report into Tallulah’s death. The College is involved in the National Suicide Prevention Alliance Working Group on the Online Environment. Over fifty national organisations have signed up to the Alliance, working together so that fewer lives are lost to suicide and to support those who are bereaved or affected by suicide. The Online Environment Working Group is looking at possible areas of work that the group could undertake relating to suicide and the online environment. The College lead for Public Mental Health a has been working with NHS England, the British Transport Police and the railways board to; e consider appropriate training; e consider necessary evidence to improve clinical practice; and e establish a systems-based public health approach involving local authorities and trusts as well police, media, NGOs and the rail industry. Specifically on training on the role of media in the Child and Adolescent Curriculum, in the current (2013) curriculum for Higher Training, there is a selective Independent Learning Objective (ILO 19) on Public Health which includes ILO 19.4 "Promoting mental wellbeing and prevention of mental illness, including liaison with the media." Within this ILO there is a post-Certificate of Completion of Training Mastery performance objective that includes "communication to the general public via public media” "awareness of the impact of media coverage on mental well-being and the responsibility of providing up to date accurate information" and "ability to explain complex ideas to children, young people and their families and the media in a way that they can understand." Although this is at present a non-compulsory part of the curriculum, in light of the increasing use of, and issues surrounding, social media, the Child and Adolescent S O | | epartment f Health Psychiatry Faculty will recommend to the Dean that these competencies are made compulsory in the next curriculum revision and recommended at pre-specialist registration stage. Oo Finally, I believe that it is important that all professionals who work with children and young people have access to information about mental health. Norman Lamb, the Minister for Care Services, is launching an interactive e-learning tool for children and young people’s mental health on 25 March. This is aimed at health professionals who are not necessarily mental health specialists, teachers, social workers and anyone working with children and young people. The Royal College of Psychiatrists is part of the consortium of organisations headed by the Royal College of Paediatrics and Child Health developing this exciting tool. The loss of a young person in such tragic circumstances is always a matter for concern, and J am grateful to you for bringing the circumstances of Tallulah’s death to my attention. I hope that this response is helpful. tuo shacedh a JEREMY HUNT
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