Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0014, written 16 Jan 2015. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 16 Jan 2015 |
|---|---|
| Reference | 2015-0014 |
| Deceased | Robert Anstice |
| Coroner | Jacqueline Lake |
| Coroner area | Norfolk |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Norfolk and Suffolk NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1)
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
The Chief Executive
Norfolk and Suffolk NHS Foundation Trust
Trust Headquarters
Hellesdon Hospital
Drayton High Road
Norwich
NR6 5BE
1
CORONER
I am JACQUELINE LAKE, Senior Coroner, for the coroner area of NORFOLK
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.
3
INVESTIGATION and INQUEST
On 29 September 2014 I commenced an investigation into the death of Mark Robert
Anstice, aged 38 years. The investigation concluded at the end of the inquest on 13
January 2015. The conclusion of the inquest was medical cause of death: 1a) Fatal
compression to the neck and narrative conclusion: Mr Anstice hanged himself. His
intention at the time is not known.
4
CIRCUMSTANCES OF THE DEATH
Mr Anstice had a history of mental health and social problems, leading to previous self
harm. He moved to Norfolk in 2012. Towards end 2013/beginning 2014 his mental
health deteriorated with feelings of isolation. He became more withdrawn. In July 2014
he considered taking his own life and was referred to the Access and Assessment Team
(AAT). Due to further problems, he was assessed under the MH Act on 3 August 2014.
He was seen by Psychiatrist on 12 August 2014, who recommended a Support
Worker/Care Co-Ordinator and review. There was an overdose on 27 August 2014,
when he was admitted to WSH as a voluntary patient. He was discharged 3 September
2014, to Bury North IDT. Mr Anstice did attend a Group Session on 5 September 2014,
but otherwise was not spoken to by Bury North IDT despite attempts made to telephone
on 5 and 8th September 2014. Mr Anstice did not attend a Group Session on 12
September 2014. On 17 September 2014, Mr Anstice was discharged from Bury North
IDT to the care of GP. An Appointment with the Psychiatrist was brought forward to 8
October 2014 at request of Mr Anstice’s partner. On 25 September 2014 Mr Anstice was
reported as a missing person. He was found hanged on 27 September 2014.
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.
1
The MATTERS OF CONCERN are as follows. –
(1) On 12 August 2014 Psychiatrist recommended Mr Anstice would benefit from a
Support Worker and/or Care Co-Ordinator – this was not actioned. The reason for this is
not known – it was indicated this may be due to an administrative problem;
(2) It was recommended a referral be made for a Carer’s Assessment on 1 September
2014. It is not clear this referral was made. Even if it had been made there would be
difficulties with assessment and provision of the service in view of the fact Mr Anstice
resided in Norfolk and the service would be provided by Suffolk MH Team
(3) The appointment arranged with the Psychiatrist for 12 November 2014 was not
known by other members of the Team, despite Team Meetings being in place to discuss
Mr Anstice’s care.
(4) It was recommended to Mr Anstice he attend Group sessions to help overcome
feelings of social isolation, whilst being unaware as to whether Mr Anstice was physically
able to attend those Group sessions. He did not have the transport or means to attend
such groups.
(5) When it became known to the IDT that Mr Anstice did not have the transport or
means to attend the Groups, consideration was given as to how to help him overcome
those practical difficulties but Mr Anstice was not informed that help was being
considered.
(6) Mr Anstice was discharged from Bury North IDT on 17 September 2014, being
invited to attend Groups and having attended one on the 5 September 2014. However
IDT were unable to speak with Mr Anstice by telephone on 5 September 2014,
8 September 2014 (tried 3 times) and he did not attend Group session on 12 September
2014.
(7) At the time of Mr Anstice’s discharge from Bury North IDT, IDT were unaware Mr
Anstice had an appointment with a Psychiatrist on 12 November 2014.
6
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe your
organisation has 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 13 March 2015 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:
(Partner)
(Father)
I am also under a duty to send the Chief Coroner a copy of your response.
2
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.
9
16 January 2015 …………………………………………..
Senior Coroner for Norfolk
3
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