Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0206, written 29 May 2015. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 29 May 2015 |
|---|---|
| Reference | 2015-0206 |
| Deceased | Melanie Amundsen |
| Coroner | Derek Winter |
| Coroner area | Sunderland |
| Category | Other related deaths |
| Organisation named | Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust |
| 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.
Derek Winter Senior Coroner for the City of Sunderland Stn tl tie REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: ACAS (The Advisory, Conciliation and Arbitration Services) 1 | CORONER ! am Derek Winter, Senior Coroner for the City of Sunderland 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.ul/uksi/2013/1629/part/7/made 3 INVESTIGATION and INQUEST On 15" September 2014 | commenced an investigation into the death of Melanie Jane Amundsen, aged 55. The investigation concluded at the end of the Inquest on 28" May 2015 with the conclusion of a Misadventure. 4 CIRCUMSTANCES OF THE DEATH On 12th September 2014 at 7am Melanie Jane Amundsen was found in a bedroom at 8 Arden Square Farringdon Sunderland. Paramedics attended and her death was confirmed at 7.30am. Melanie Jane Amundsen who was a vulnerable adult had consumed a fatal amount of alcohol notwithstanding family support and a history of engagement with mental health services to support her. 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. — Not every employer or employee may have an awareness of mental health issues in the work place, and in particular in respect of disciplinary processes. Whilst ACAS (The Advisory, Conciliation and Arbitration Service) have a very informative website and publications, there may be scope for it to be enhanced and better publicised so that both, employers and employees may have that awareness and act upon it. 6 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. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely Civic Centre, Burdon Road, Sunderland, SR2 7DN Tei 0191 5617843 | Fax 01915537803 | DX 60729 Sunderland www.sunderland.gov.uk/coroner by Monday 27” July 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. COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the following Interested Persons: - ¢ Family and their Solicitors e Northumberland, Tyne and Wear NHS Foundation Trust and their Solicitors | have also sent a copy of my report to the following, who may find it useful or of interest: - e Villette Surgery e Northumbria Police e Nursing and Midwifery Council e Encompass Health Care !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 this 29" day of May 2015 Signature Senior Coroner Tor
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