Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0303, written 31 Jul 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 31 Jul 2014 |
|---|---|
| Reference | 2014-0303 |
| Deceased | Nadine Thurman |
| Coroner | Robin Balmain |
| Coroner area | Black Country |
| Category | Hospital Death (Clinical Procedures and medical management) 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.
Smethwick Council House
High Street
Smethwick
; ; West Midlands
Robin J. Balmain
H.M. SENIOR CORONER miatainie
F esiicw ape 3!
Tel;
BLACK COUNTRY CORONER'S DISTRICT a
(SANDWELL ° DUDLEY * WALSALL » WOLVERHAMPTON a
Metropolitan Borough Councils) a
Date: Date 3 July 2014 Our Ref: RUB Your Ref:
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
Clinical Governance Facilitator
Dudley & Walsall NHS Mental Health
Partnership NHS Trust
Clinical Governance Dept., 76 Ida Road
Walsall WS2 9SS
Re: Nadine Gillian THURMAN deceased
Ay CORONER
1 Robin John Balmain am the Senior Coroner for the Black Country Coroners
Jurisdiction
Ds CORONER’S LEGAL POWERS
I 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
This investigation was commenced on 12 November 2012 and concluded on 234
June 2014. A conclusion was reached that the deceased hung herself whilst suffering
from an anxiety related disorder.
4. CIRCUMSTANCES OF THE DEATH
There was a history of paracetamol and vodka misuse on 19 October 2012 following
treatment she was seen by the crisis team. On 28 October 2012 there was a further
misuse of paracetamol and hospital treatment and again seen by the crisis team. On
5t November 2012 Mrs. Thurman was found hanging at home.
5, CORONERS CONCERNS
The MATTERS OF CONCERN are as follows :-
My concerns relate to the psychiatric assessment of Mrs. Thurman.
gave evidence to me that he was not allowed to contribute to the assessment. I was
told that Mrs. Thurman was asked by a nurse if she was content to be seen on her
own. That seems to me to be an approach that is suggestive of the answer and is
This Office is open Monday to Thursday 8am to 4pm. Friday 8am to 3pm
SENIOR CORONER
03 July 2014 Continuation
a SS SS SS LS SES
likely to exclude relevant information. It seems to me that the approach to someone
being assessed should be along the lines “Are you happy for your family to be
involved in and make a contribution to the assessment”. 1 was also told by a
hospital nurse that on contacting the crisis team to ask if a relative could be present,
the crisis team always refuse.
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe you 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 the
report, namely by 28 August 2014.
COPIES and PUBLICATIONS
I have sent a copy of my report to the Chief Coroner and es ::.
husband.
Iam 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 iyffefest, You may make representations to me, the Coroner, at the time of
aur responge, abou'\the release or the publication of your response by the Chief
RJ. Balmain
Senior Coroner
BAP
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