Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0484, written 10 Nov 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 10 Nov 2014 |
|---|---|
| Reference | 2014-0484 |
| Deceased | Mark Hancock |
| Coroner | Joanne Kearsley |
| Coroner area | Manchester South |
| 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.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: The Priory Group 1 | CORONER | am Joanne Kearsley, Area Coroner, for the coroner area of South Manchester 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 3 | INVESTIGATION and INQUEST On 13" February 2014 | commenced an investigation into the death of Mark Hancock dob 25.09.1971. The investigation concluded on the 27" October and the conclusion was one that the deceased had taken his own life. The medical cause of death was recorded as 1a) Multiple Incised Wounds 4 | CIRCUMSTANCES OF THE DEATH | heard evidence that the deceased had a history of mental health difficulties. His condition had deteriorated towards the end of 2013. He was receiving treatment at the Priory Hospital and had a diagnosis of severe clinical depression. Following his diagnosis he was treated with medication and therapy. On the 8" February the deceased had superficially cut his wrists. This had not required any medical intervention. On the 11" February 2014 he was attending the therapy group and at the lunch time had an appointment with his Consultant. During the course of the morning it had been noted by his therapist that the deceased was presenting differently. He was withdrawn and not participating. He was then seen by his Consultant who concluded that the deceased required hospital admission. There were no beds available due to an incident on the ward. A decision was taken that the deceased could return home to his parents’ house and would be admitted the following day. On his return to the afternoon therapy session there was increased concern by the therapist who escalated his concerns about the deceased. There was then a further discussion with his consultant but the plan remained the same. The deceased returned home to his parents’ house where he appeared settled. In the early hours of the 42h February 2014 he was found by his parents to have smashed a glass and inflicted a number of serious wounds to himself particularly to his throat and thigh. 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. — - The quality of the records kept in relation to the deceased was poor and in some circumstances non-existent. No records were kept of the Multi-Disciplinary Team Meetings. - The Consultant notes were brief and are not kept on the Care Notes system. Such a diverse practice means that there is no overall record of a patient so that all those who have involvement with a patient do not have all relevant, pertinent information available to them. - No documented risk assessment was completed in relation to the risk the deceased posed to himself. - No further assessment of the deceased was undertaken by the Consultant after concerns had been escalated following his departure from the group therapy. - The consultant's out-patient appointment with the deceased had been booked to take place in the lunchtime when he was already in a full day therapy session. - When concerns were raised in relation to the deceased the further discussions took place in the reception area, an inappropriate environment in which to speak to a patient and obtain important information. - Given there was no formal risk assessment there was no consideration as to whether the risk management plan was appropriate. - There was no procedure or policy in place for staff as to what they should do if a patient requires admission but a bed is not available. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | 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 this report, namely by 5 January 2015. |, 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 co) fm i ing Interested Persons namel . | have also sent it to Greater Manchester Police who may find it useful or of interest. | 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. Date 10/11/2014 Joanne Kearsley HM Area Coroner Manchester South
See every Prevention of Future Deaths report matching Hospital Death (Clinical Procedures and medical management) 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.