Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0390, written 2 Sep 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 2 Sep 2014 |
|---|---|
| Reference | 2014-0390 |
| Deceased | Peter Stanley |
| Coroner | Peter Dorries |
| Coroner area | South Yorkshire (West) |
| Category | Alcohol, drug and medication related deaths |
| 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: REPORT TO PREVENT FUTURE DEATHS
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
1. Rt. Hon. Nicky Morgan MP, Secretary of State for Education
2. Rt. Hon. Lord McNally, Chair of the Youth Justice Board
3. The Chief Constable, South Yorkshire Police
4. Chief Executive GeoAmey
Note that the report is not addressed to the Sheffield City Council as the evidence at the inquest
satisfied me that they have already dealt with the points herein so far as relevant to them.
1
CORONER
Christopher Peter Dorries, senior coroner for the South Yorkshire (West) area.
2
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.
(1)
(a)
Where –
A senior coroner has been conducting an investigation under this Part
into a person’s death
Anything revealed by the investigation gives rise to a concern that
(b)
circumstances creating a risk of other deaths will occur, or will continue to exist, in the
future, and
In the coroner’s opinion, action should be taken to prevent the occurrence or
(c)
continuation of such circumstances, or to eliminate or reduce the risk of death created
by such circumstances, the coroner must report the matter to a person who the coroner
believes may have power to take such action.
A person to whom a senior coroner makes a report under this paragraph must
(2)
give the senior coroner a written response to it.
A copy of a report under this paragraph, and of the response to it, must be sent
(3)
to the Chief Coroner
3
INVESTIGATION and INQUEST
On 2 August 2013 I commenced an investigation into the death of Peter Stanley (aged
17). The investigation concluded at the end of the inquest on 22nd July 2014.
The conclusion of the inquest was that Peter took his own life by hanging but that there
1
had been a number of missed opportunities to assist him by way of mental health
assessment and care over the preceding weeks, most particularly towards the end of his
life. However, it could not be said on the balance of probabilities that Peter would have
survived if any or all of the opportunities had been taken.
CIRCUMSTANCES OF THE DEATH
4
Peter Stanley, aged just 17, was found hanging in woodland on the outskirts of Sheffield
on 2nd August 2013.
There was a history of concern regarding Peter's mental health, his problems possibly
originating from use of a so called 'legal high'. An assessment by an experienced
community mental health nurse (CMHN) at the end of 2012 recognised that Peter could
be developing a psychosis and he was offered a care-coordinator. Unfortunately Peter
subsequently refused to engage. It was felt better that the service withdrew with an
open invitation for Peter to re-engage when he was ready rather than 'harass' him and
potentially spoil chances of later engagement.
On the 10th April 2013 Peter presented himself to the local authority as 'homeless'
because his parents could no longer cope with his behaviour. He was seen by a
housing officer and social worker. Peter did not want to be 'looked after' (that is go into
the care of the authority) and a bed was found at a suitable establishment
('Roundabout') to provide assessment and help with more immediate issues.
On the 3rd May Peter saw his own GP complaining of an injury to his back from 'falling
downstairs'. Although not disclosed at the time it is clear that Peter suffered this injury
when attempting to hang himself on stairs at his mother's address. The significant
nature of his injury suggests a violent episode and given his non-disclosure at the time it
would be difficult to see this as anything other than a serious attempt on his life.
On 14th July Peter committed a serious and violent episode of damage at Roundabout.
He was barred from the premises and thus rendered homeless.
Peter was arrested for the damage and seen in the detention area by a custody nurse,
because he had been banging his head on the wall. He denied any history of mental
health issues and said he was only banging his head to cause trouble. Because of his
behaviour Peter was subject to constant supervision in the police cells. He also required
full bodily restraint at one point.
Peter appeared before the Magistrates from custody next day (15th July) and was made
subject of a referral order to the Youth Justice Service. The Youth Justice team (YJT)
were not made aware of the bizarre behaviour in custody and arrangements were simply
made to see him a week later.
Later that morning Peter (now homeless) attended at the local authority Housing Dept
with his father, although
social worker from Children's Services (SWCS) was also present. Housing had little to
offer because of the circumstances in which Peter was removed from Roundabout and
as there was no supported bed provision available he was declared 'intentionally
homeless'. This left Peter to continue within the responsibility of Children's Services.
was not in the room for much of the interview. A
Peter made a disclosure during this interview about his suicide attempt on the stairs but
not whilst his father was present. In fact
serious attempt on the stairs whilst Peter was alive.
never knew of the apparently
There were continuing but unsuccessful efforts to find Peter more suitable
accommodation than the Bed and Breakfast initially allocated. The SWCS apparently
2
felt that the YJT would be the quickest route to a mental health assessment — but
despite discussion about Peter the YJT were not given any information about the mental
health history or needs and nothing was put in progress.
Although the Children's Services record system clearly identified the CMHN's previous
involvement, he was not contacted at any time before Peter's death
On 31st July a YJT substance misuse worker, saw Peter for a drug screen (not in
relation to mental health). Peter told her of many thoughts about suicide, of his attempt
on the stairs now four months before and of hearing voices. He said that he felt very low
and was so distressed that he wanted to run into oncoming traffic or slice his own leg off.
He felt that he had very little support from anyone and feared that he might be
schizophrenic.
This was taken seriously and a meaningful risk of self-harm was recognised although
not seen as immediate. An appointment to see the YJT mental health worker (who was
on leave) was made for a few days hence. The SWCS was contacted but there was little
more provided. Further action was left with the YJT pending the mental health
assessment the following week. The YJT determined to support Peter pending the
assessment -- but were not really equipped to do so. No contact was attempted with
Peter's father, nor any attempt to seek a medical view of the situation by telephoning
Peter's GP.
The following day (1st August) Peter did not attend a planned course. The YJT
telephoned him twice. The first time he was plainly under the influence of drugs/alcohol
and said he was unwell. When called later he was incoherent. The YJT became very
worried and called the SWCS. Nothing seems to have come from this save that
arrangements were made for an out of hours team to telephone Peter each morning
over the coming weekend. Peter's whereabouts were unknown as he was not at the
B&B.
In fact, Peter was actually with his father that same afternoon. He described Peter as
withdrawn, abrupt and intolerant. He plainly didn't see his son as suicidal but then he
had no knowledge of either the earlier attempt or of the disclosures to the substance
misuse worker. They parted when he took Peter back to the B&B as he felt his
behaviour was not acceptable for a planned visit to the family home.
Peter's body was found some hours later. The circumstances were plainly of a
deliberate self-hanging.
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) Peter's mental health problems may have stemmed from the use of a so called 'legal
high'. I understand that some, but not all, mainstream insurers have been persuaded to
adopt a policy of not offering cover to establishments that sell such substances. Can
this be encouraged further?
(2) When young people are discharged from, or have failed to engage with, Adult
Mental Health Services there is no formal 'step-down' policy. The Sheffield Child Death
3
Overview Panel advise me that this should include a referral to a Multi Agency Support
Team or Community Youth team who can then establish a key worker and 'team around
the child' approach.
(3) On the basis of evidence given by
Fieldwork Services, Sheffield City Council, it is clear that the custody nurse could have
accessed the Children's Services records for Peter on 14 July, even during the night, by
calling the Social Services 'out of hours' team. Every local authority has an out of hours
system (which would cover adults as well). However I am told that this is not generally
known amongst those providing custody medical services.
Assistant Director of
(4) There is no specific requirement that health professionals completing assessments
of young persons in custody suites include a thorough assessment of mental health.
(5) A prisoner escort record (known commonly as a PER) would have been handed
over from the police to the privatised court detention officers when Peter was produced
before the magistrates. This contains details (inter alia) of risks, self harm issues,
medical attention and warning markers. I understand that the Youth Offending Service
believe that the PER should be routinely given to them it would inform assessments as
to the immediate needs of the young person. This would only arise, of course, in the
relatively few cases where the young person has spent a period in police cells.
(6) Peter was classed as 'intentionally homeless' after his release from court on 15 July.
gave the court compelling evidence that this was wrong and that Peter
should have been treated as a 'Child in Need'. Emphasis on the 'Child in Need' process
when a young person was homeless would ensure proper assessment and sharing of
information. Failures in sharing Peter's mental health history/needs were significant
issues in this case. This emphasis is now standard practice in Sheffield but I understand
it is not likely to be the case everywhere.
(7) This case shows the need for a greater number of places in supported
accommodation.
(8) The Sheffield Child Death Overview Panel have also recommended that no young
person should be deemed intentionally homeless.
(9) It is evident that front line social services practitioners are not always aware of when
and where to make mental health referrals.
(10) It is understood that the number of Youth Offending Service staff who have access
to, and training for, the Social Services records system is limited.
(11) There is no system to ensure that where there has been previous psychiatric
services involvement by a young person that such information will be used to inform
assessment and the 'Child in Need' planning process.
(12) There is no system to ensure that when a young person has presented with
previous suicidal ideology that advice is taken from health professionals regarding the
potential risks.
(13) There is no system to ensure that 16 and 17 year olds placed in supported
accommodation have needs based access to support services, including mental health
and substance misuse, irrespective of whether they fall within s.20 of the Childrens Act.
4
6
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.
7
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report,
namely by 29 October 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 Chief Coroner and to the following Interested
Persons:
Exec Director for Children, Young People & Families, Sheffield
the family of Peter Stanley
City Council (copy to City Solicitors Dept)
Sheffield Health & Social Care Trust
I have also sent it to the following who may find it useful or of interest:
Sheffield Child Death Overview Panel.
Edward Timpson MP, Under Secretary of State (portfolio for children & families)
Youth Justice Team, Sheffield.
Chief Executive, Medacs Healthcare, Luton.
Clerk to the Justices, Sheffield.
Chief Executive, Roundabout.
, Hon. Secretary, Assoc. of Directors of Children's Services
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 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.
2 September 2014 Christopher P. Dorries
9
5
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.
eS
National Offender
Management Service
Head of Custodial Contracts & PECS
National Offender Management Service
3 Floor, Clive House
70 Petty France
London SWI1H 9EX
- Mr C P Dorries
HM Senior Coroner
The Medico-Legal Centre
Watery Street
Sheffield
S3 7ET
27" January 2015
Dear Sir
RE: Peter Stanley Deceased (ref 14¢mj210.Staniey)
1 write to acknowledge receipt of your Regulation 28 notice which you have redirected from
our contractor Geo Amey to myself as Head of the Prisoner Escort Custody Service (PECS).
Although PECS only implement policy on safer custody which is set by NOMS centrally
rather than redirect your notice for a third time | am content to respond on behalf of the wider
organisation and have copied the appropriate policy lead into this correspondence,
| note your recommendation that a prisoner escort record (PER) is routinely handed over
from the police to the private escort contractor when the prisoner is produced before the
Magistrates which contains details of risks, self harm issues, medical attention and warning
markers and. that this information should be routinely shared with the Youth Offending
Service.
| can confirm that PECS entirely accepts your recommendation and we have reviewed our
contractor's operational policies to ensure that their staff understand and adhere to this in
future. ;
We already contractually require Geo Amey to comply with NOMS policy which in this case
is set out in Prison Service Instruction 64/2011 (Management of prisoners at risk of harm to
self and others (Safer Custody)).
PECS has agreed with the police via ACPO that information on risk relating to detainees
(including risk of self-harm and suicidal intent) is communicated via the Prisoner Escort
Record (PER) form. It is this information supported by the receiving staffs own dynamic
assessment of risk that informs the form of care the individual will receive. This may in
exceptional circumstances include the removal of clothing, continuous observation by staff
etc but this is not the normal default position. Our policy and adherence to it is subject to
periodic review by NOMS Internal Audit and external assessment by HM Inspectorate of
Prisons as part of their Court Custody Expectations visits.
The content of the PER form can be shared with any appropriate party who needs access to
the prisoner in order to conduct interviews or assessmenis. We have taken steps to remind
’ Geo Amey that employees of the Youth Offending Service clearly fall into this category. This
will be reinforced in staff briefings and safer custody training going forward. .
NOMS is currently reviewing the format and content of the PER form as part of our work with
the Ministerial Council on Deaths in Custody. | will ensure that the findings of this inquest are
communicated to the NOMS team involved in this work.
| will also feedback any learning and outcomes of this meeting to NOMS Safer Custody
Team in order that it can contribute to the development of our own policies and procedures
going forward.
{can confirm | have no issue with this response being shared in full with the Chief Coroner.
Yours faithfully.
Head of PECS
cc: ME. SCDM Geo Amey PECS contracts
HE NOMS Safer Custody
See every Prevention of Future Deaths report matching Alcohol, drug and medication related deaths, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.