Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0454, written 21 Oct 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 21 Oct 2014 |
|---|---|
| Reference | 2014-0454 |
| Deceased | Mary Stroman |
| Coroner | David Ridley |
| Coroner area | Wiltshire & Swindon |
| Category | Other related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
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REGULATION 28 REPORT TO PREVENT FUTURE DEATHS DAVID W. G. RIDLEY Senior Coroner for Wiltshire and Swindon THIS REPORT IS BEING SENT TO: Mr Nick Walkley Chief Executive Haringey Council 5th floor River Park House London N22 8HQ 7 CORONER lam DAVID W. G. RIDLEY, Senior Coroner for Wiltshire and Swindon 2 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. http://www. legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www. legislation.gov.uk/uksi/2013/1629/part/7/made INVESTIGATION and INQUEST On 16 January 2014 | commenced an investigation into the death of Mary Elizabeth Grace Stroman, aged 16. The investigation concluded at the end of a two day inquest on 16 October 2014. The conclusion of the inquest was that Mary took her own life whilst suffering from Complex Post Traumatic Stress Disorder. On 15 January 2014 she lay down on a railway line and was struck by a train between the stations of Westbury and Trowbridge in Wiltshire and died as result of multiple injuries. CIRCUMSTANCES OF THE DEATH Back in 2010 Mary's family lived in Hackney and their GP was based in Islington. Problems began to appear towards the end of 2010 that resulted in Mary becoming a voluntary inpatient at the Priory North in December 2010. | found as a fact that Mary's Post Traumatic Stress Disorder that was subsequently diagnosed in 2011 was linked to mental trauma sustained as a result of episode(s) of sexual abuse. Expert opinion suggested that the index episode may have occurred 12 months prior to this possibly slightly earlier than that. There more likely than not were repeated incidents. The family moved to Haringey in the summer of 2011. It is quite clear from the evidence that | heard that there were concerns from a safeguarding perspective in relation to Mary's safety away from the family home in the community and in 2012 as early as February 2012 the Consultant Adolescent Child Psychiatrist, ana part of the Wittington Healthcare Trust was of the view that Mary would benefit from long term therapeutic placement for up to 3 years which could meet her educational needs whilst maintaining her safety away from the area and in particular the Lond ington. That placement finally began in June 2013. In Wiltshire she was seen . last consultation was 07 January 2014 where Mary was not exhibiting suicidal ideation or indicating a plan. For some reason which is unclear as contact with Mary throughout the day of her death indicated that there was nothing as regards Mary's behaviour that caused concern. She was in fact described as perky however at some point after 1920 on Wednesday 15 January 2014 she changed her clothes and walked some 800m to a nearby railway line where she proceeded to lie down on the track in front of an oncoming service from Portsmouth to Bristol. She died as a result of the multiple injuries she sustained in the collision. Wiltshire & Swindon Coroner's Office, 26 Endless Street, Salisbury, Wiltshire, SP1 1DP Tel 01722 438900 | Fax 01722 332223 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) Delay in the decision making process as regards funding the long term 2 _— therapeutic placement As early as February 2012 as indicated in the previous section was supportive of the need for Mary to be placed on a therapeutic placement scheme away from the London Borough of Islington. That view was supported a Priory North and | am aware that they wrote to your local authority in November 2012 expressing their concerns due to the lack of progress. Due to the involvement of Islington who were supportive of the proposal from a healthcare perspective Mary's educational and Child social services responsibilities fell to your local authority following the family’s move to Haringey during the summer of 2011. | heard evidence in the form of a report from a... stated that at a Haringey Complex Care Panel Meeting on the 09 May 2012 it was agreed that Mary's case for joint funded placement would be advanced. A letter from the panel subsequently stated that it accepted that Mary's needs to be given the opportunity to live outside the family home and that a range of options were going to be explored. | was informed by EEE that this decision was overturned by Children’s Services on the basis it did not meet a threshold for accommodation under Section 20 and that it would not be in Mary’s best interests. | am aware of the involvement of a local MP and the Stroman Family's lawyers who highlighted the local authority's duty here in terms of context and it was not until March 2013 that funding was authorised by your local authority. Again in] report he makes reference to a further report being commissioned by Haringey Children’s Services in September 2012. The assessment was completed by I and it concluded “My experience.... may be reflective of the paralysis within the care system around this patient but ultimately of the patient's own predicament’. Whilst in the terms of Mary's Inquest | did not find a direct causal link between the delay in funding Mary's placement | am concerned in relation to future cases that could impact on an individual’s mental state and mental health. It is quite clear from the expert opinion evidence that | have read Mary’s educational needs in particular were not being satisfied in either Simmons House or Priory North hence aan tia recommendation. The welfare of the child must be paramount and | would ask that you review the practises and procedures that were adopted here resulting in the decision to fund Mary’s long term therapeutic placement with a view to ascertaining as to whether or not lessons could be learned with a view to improving the process and reducing the delay. | fully appreciate that Mary’s case was exceptionally complex but | am concerned that the delay could affect other individuals if placed in a similar situation that may lead to self harming and even death. The temporary termination of the placement at Tumblewood - August/September 2 As part of the evidence | was aware that Mary's placement was temporarily terminated as a result of an OFSTED inspection. Many pupils at Tumblewood including Mary arrive with a history of disrupted education. One of the reasons Mary was placed at Tumblewood was for this reason given her significant history of time as a voluntary inpatient in hospital and as an inpatient at another establishment both of which were felt by those involved not to address and meet her educational needs sufficiently. | am concerned as part of the process here that given that there was joint funding that the decision to terminate appears to be have been taken by your local authority without consultation with the other partner involved - Islington. | am additionally concerned as regards the general decision making process here assessing the safeguarding risk as compared to the benefit of allowing Mary to continue and return to her placement after the holiday period to an environment that provided stability rather than_a_ situation Wiltshire & Swindon Coroner's Office, 26 Endless Street, Salisbury, Wiltshire, SP1 1DP Tel 01722 438900 | Fax 01722 332223 whereby the alternative did not address her educational needs and was unsettling. At the Inquest | was satisfied that at the time of her death any issues that arose following her forced absence from Tumblewood were being addressed from the educational perspective which included involving Mary in that decision making process and that there was no direct causal link with her death. My concern is as regards the way your authority handles matters in the future which could potentially unsettle an individual's mental state possibly resulting in self- harm or even death. Again can | ask you to review the matter with a view to looking to identify any learning points and to communicate them back to me? In evidence | was unaware of any other pupil whose placement had been terminated as a result of the same report. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you Mr Nick Walkley, Chief Executive of Haringey Council has 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 16 December 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 Kingley Napley LLP and to the LOCAL SAFEGUARDING BOARD | 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. Dated 21 October 2014 Signature 2S Senior Coroner for Wiltshire and Swindon Wiltshire & Swindon Coroner's Office, 26 Endless Street, Salisbury, Wiltshire, SP1 1DP Tel 01722 438900 | Fax 01722 332223
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.
Chief Executive 5" Floor, River Park House, 225 High Road, Wood Green, London N22 8HQ Tel: 020 8489 2648 Fax: 020 8489 2906 www.haringey.gov.uk Chief Executive NickWakley Haringey Council David Ridley Coroner for Wiltshire and Swindon Your ref: 28 Endless Street Date: 23 July 2018 Salisbury Our ref: Wiltshire Direct dial: 020 8489 2648 SPT IDE By email and post Dear Mr Ridley, Regulation 28 report touching the death of Mary Elizabeth Grace Stroman Thank you for your letter dated 21st May 2015 and also for the extension of time granted until Friday 24th July 2015 to respond to your report. | recognise that the series of actions and decisions from Haringey Children’s Services could have been different and it is important that lessons are learned from this tragic case. | fully appreciate that it would not be acceptable to seek a further deferment of my response to you. Therefore | am responding today directly on behalf of the local authority, whilst acknowledging that the issues you have raised may well be further addressed in the SCR (Serious Case Review) when it is completed by late September. | welcome you raising the two specific points and | am keen to share our learning and subsequent actions with you. In response to ‘the delay in decision making, Processes as regards funding the long term therapeutic placement’, | recognise that there were delays in the decision to fund the Placement and | also accept that Children’s Services management, including the overall oversight and direction, of this case could have been better, Systems are now much improved, including; ¢ Strengthened management and oversight over decision making in our cases, including the timeliness of assessments. This, alongside other indicators of quality are reviewed and further scrutinised by the Director of Children’s Services in weekly performance meetings with all Heads of Service. e Importantly there has also been a significant improvement in joint working with partner agencies. The functioning of the Complex Care Panel (which looks at cases of this nature) has been refreshed with revised membership, including the lead commissioner from Haringey Commissioning Group. This has enabled more effective information sharing and will lead to increased timely and informed decision making relating to our joint funded placements. In terms of the decision to ‘temporarily terminate the placement at Tumblewood in the autumn 2013’, | fully accept that Children Services decision to suspend the placement could have been better managed; in particular Islington CCG should most certainly have been consulted before any decision was made. The report you provided has been a valuable opportunity to reflect and gain some essential learning points which have resulted in a number of improvements to ensure that this type of situation does not arise again. ¢ At the point of making a placement, we make it clear to parents and partners that we will only make placements in an establishment that are graded good or outstanding by Ofsted and if the establishment grade at any stage changes to inadequate, we will complete a risk assessment and consult with partners and also parents to make an informed decision (based on the particulars of each individual case). e An Independent Review Manager at the six monthly review meeting checks that there is a clear plan for the young person including contact and holiday arrangements. In terms of the wider partnership, given that in this case there was disagreement between Children Services and health partners, | am assured by the Director of Children Services that there is an Ongoing and concerted effort to bring partners closer together, to work as effectively as possible, to enable the best outcomes for children and families. | note that it is acknowledged in your report that there is no direct causal link between the delays and the temporary suspension and the tragic incident. Despite this, we sincerely regret that our management of the case was not as effective and timely as it should have been. Whilst Children Services have taken Steps to apply the learning and address issues raised, there may be further findings and recommended actions arising from the SCR report. These will be shared with staff to ensure lessons are learnt with urgency as part of our continued programme of improvements. Once | have received the organisation response to the SCR, | would be happy to share the findings and action plan with you. Again, | thank you for your report and for bringing these issues to my attention. Yours sincerely Chief Executive Po Independent Chair, Haringey LSCB
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