Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0285, written 25 May 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 25 May 2014 |
|---|---|
| Reference | 2014-0285 |
| Deceased | Michaela Christoforou |
| Coroner | Andrew Walker |
| Coroner area | London (North) |
| Category | Care Home Health related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
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.
, North London Coroners Court, Her Majesty's Coroner for the 29 Wood Stes Northern District of Greater London —Bamet ENS 4BE (Harrow, Brent, Barnet, Haringey and Enfield) Telephone 0208 447 7680 Fax 0208 447 7689 INVESTIGATION and INQUEST REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Care UK, 10 Lansdown Stroud, GL5 1BB CORONER lam Andrew Walker, senior coroner, for the coroner area of Northern District of Greater London 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. On the 24” April 2013 | opened an inquest toughing the death of Michaela Jade Christoforou , 17 years old. The inquest concluded on the 28" April 2014. The conclusion of the inquest was suicide, the medical case of death was 1a Hypoxic Brain Injury, 1b Hanging and 1c anorexia nervosa and depression . CIRCUMSTANCES OF THE DEATH Michaela was 17 years old at the time of her death and a patient at Rhodes Farm Hospital in North London. Michaela was suffering with an eating disorder and a risk of suicide and in the period leading up to her death was not able to leave hospital without the consent of the medical staff looking after her. In January 2013, whilst at home, following an overdose and an attempt at hanging herself, Michaela returned initially to Forest House Adolescent Unit, a bedded unit for young people between the ages of 12 to 18 and then on the 18! January to Rhodes Farm Hospital, a 24 bedded specialist child and adolescent eating disorder service. On the 24t January 2013 Michaela was detained under section 3 of the Mental Health Act 1983 and had to stay in hospital unless her doctors Her Majesty’s Coroner for the Northern District of Greater London (Harrow, Brent, Barnet, Haringey and Enfield) allowed her to leave the hospital. On the 14 April 2013 Michaela was in hospital when found with bunting around her neck suspended from a metal locker in a classroom at the hospital. Michaela was taken to St Mary’s Hospital Paddington where she died sadly on the 17" April 2013. 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. ~ That all staff at the unit did not carry with them a ligature cutter. 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 Tuesday 5" November 2013. |, 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;- Members of Michaela’s family, Care UK, 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 pyblication of your response by the Chief Coroner. —_— i Tr 25" May 2014
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.
Her Majesty's Coroner for the Northern District of Greater London North London Coroner’s Court 29 Wood Street Barnet ENS 4BE For the attention of HM Coroner Andrew Walker 11" August, 2014 Dear Sir, Cafe & Care UK Connaught House 850, The Crescent Colchester Business Park Colchester Essex CO4 90B T 01206 752552 F 0845 0524181 www.careuk.com We refer to the enclosed Regulation 28 report which was issued following the Inquest into the death of Michaela Christoforou. After considering your report very carefully Care UK wishes to inform you that we have taken and/or intend to take the following actions: 1. There are now nine sets of ligature cutters located throughout Rhodes Farm (three on each floor). 2. Clinical staff will carry ligature cutters for a six month trial period commencing in September 2014. 3. A protocol/procedure is being developed that covers all aspects concerned with the carrying and management of ligature cutters. 4. Care UK is working with a specialist knife company with the intention of developing a knife that is both discrete and tamper proof. 5. Care UK is liaising with NHS England, our customer, regarding this issue. | trust that the above action is sufficient to meet the concerns that you have expressed. If there is any further information you require please do not hesitate to contact me. Yours faithfully, Martin Davies Director Specialist Services Care UK Mental Health Partnerships Limited. Registered in England No 01833386 Registered Office: Connaught House, 850 The Crescent, Colchester Business Park, Colchester, Essex CO4 90B
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