Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0078, written 26 Feb 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 26 Feb 2014 |
|---|---|
| Reference | 2014-0078 |
| Deceased | Hazel Polkinghorn |
| Coroner | Stuart Fisher |
| Coroner area | Lincolnshire (Central) |
| Category | Mental Health related deaths |
| Organisation named | Lincolnshire Partnership NHS Foundation 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.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Crispin Blunt Esq MP Parliamentary Under Secretary of State Ministry of Justice 102 Petty France London SW1H 9AJ CORONER | am Stuart P G Fisher, Senior Coroner, for the Coroner area of Central Lincolnshire 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] INVESTIGATION and INQUEST On 29/4/13 | commenced an investigation into the death of Hazel Claire Polkinghorn (33 years), The conclusion of the inquest on 17/2/14 was a Narrative Conclusion. CIRCUMSTANCES OF THE DEATH Hazel Polkinghorn had a history of mental health difficulties extending back to her teenage years. In 2012 she was diagnosed with Emotionally Unstable Personality disorder (borderline) and Hypochondriacal Disorder. She had recently been admitted (on a voluntary basis) to a local Psychiatric Hospital between the 8" July 2012 and 10" November 2012. On the 21 November 2012 Miss Polkinghorn was transferred to Discovery House (a Psychiatric Rehabilitation Unit) once again based in Lincoln. Whilst at Discovery House she received Psychological treatment. On or about 9" April 2013 Miss Polkinghorn was discharged from Discovery House into the Community; she took up residency in a flat. A package of support had been agreed at her discharge meeting on 9" April 2013. It was established at the inquest that Miss Polkinghorn had acquired non-prescribed medication from the internet for a period of some 4 to 4 % years prior to her death. It was further established that on or about 25" March 2013, Miss Polkinghorn obtained further non prescribed medication from the internet which appears to have been despatched from Mexico. On the 24" April 2013 Miss Polkinghorn was found deceased in her flat having taken an overdose of Pentobarbital. Miss Polkinghorn left notes intimating that she intended to take her own life. 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. — Miss Polkinghorn acquired non prescribed medication from the internet. She took an overdose of the drugs so acquired and died on the 24" April 2013. | am deeply concerned regarding the ease with which Miss Polkinghorn managed to acquire Pentobarbital (and other medication) from the internet. | am particularly concerned that other similar deaths will occur unless steps are taken by Central Government to screen and close down websites such as this which are engaged in selling potentially dangerous non prescribed medication. 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. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 23 April 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 Persons on Lincolnshire Partnership NHS Foundation Trust. | 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 repo e believes may find it useful or of interest. You may make re} of your response, about the release [DATE] 26" February 2014
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