Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0037, written 5 Feb 2016. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 5 Feb 2016 |
|---|---|
| Reference | 2016-0037 |
| Deceased | Chentoori Chanthirakumar |
| Coroner | Mary Hassell |
| Coroner area | Inner North London |
| Category | Suicide (from 2015) |
| Organisation named | East London 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: Prevention of Future Deaths report
Chentoori Chanthirakumar (died 30.07.15)
THIS REPORT IS BEING SENT TO:
Dean for Education
Barts and the London School of Medicine and Dentistry
Queen Mary University of London
Mile End Road
London E1 4NS
1.
2.
Medical Director
East London NHS Foundation Trust
Trust Headquarters
9 Alie Street
London E1 8DE
1
CORONER
I am: Coroner ME Hassell
Senior Coroner
Inner North London
St Pancras Coroner’s Court
Camley Street
London N1C 4PP
2
CORONER’S LEGAL POWERS
I make this report under the Coroners and Justice Act 2009,
paragraph 7, Schedule 5, and
The Coroners (Investigations) Regulations 2013,
regulations 28 and 29.
3
INVESTIGATION and INQUEST
On 31 July 2015 I commenced an investigation into the death of
Chentoori Chanthirakumar, aged 24. The investigation concluded at the
end of the inquest on 27 January 2016. I made a determination of death
by suicide, when this young woman hanged herself at home on the night
of 29-30 July 2015.
1
4
CIRCUMSTANCES OF THE DEATH
Ms Chanthirakumar was a fourth year medical student at Barts and the
London who became acutely mentally unwell in the early part 2015. She
was admitted to Mile End Hospital on 16 June 2015 via the emergency
unit, and then spent three weeks in Crisis House before being discharged
with follow up.
Following her attendance at the emergency unit, the medical school also
became involved in supporting her emotionally.
They then sent an email to her on 29 July 2015, informing her that she
would not be able to take her examinations in August 2015, but would be
able to re-take the year.
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.
Barts and the London
1. Whilst it was clear to me from the evidence I heard at inquest that
Barts and the London, both in terms of certain individuals within it and
as an organisation, took its pastoral responsibilities very seriously
indeed and made great efforts to support this student, there was one
aspect of their processes that I think would benefit from review.
The decision that Ms Chanthirakumar could re-take the fourth year of
her medical degree was seen by the medical school as a helpful
decision. The re-take was allowed on the basis of her ill health and
was not a criticism of her academic achievement.
That she would not be able to take her fourth year examinations in
August 2015 came to be regarded as almost self evident, because
she had not been able to attend the majority of her recent clinical
placement and had been so recently so unwell.
However, unbeknown to the university staff, Ms Chanthirakumar
appears to have lacked some insight at this point, and was actually
hoping not to have to re-take the year, but instead to take her fourth
year exams in August 2015.
2
Given the very particular course of very recent events leading up to
the medical school’s decision, I wonder whether a personal meeting
to discuss matters with her could have been arranged, rather than
communicating this by email. A face to face meeting may not
necessarily have had any impact on the outcome, but nevertheless I
think would be a helpful consideration for the process in the future.
East London Trust
2. After the medical school was alerted to Ms Chanthirakumar’s illness
by two of her friends on 17 June 2015, a senior lecturer working in
student support services (and, as it happens, herself a general
practitioner) rang Globe Ward of Mile End Hospital and spoke to a
treating nurse.
Her intention in making this call was to deliver information, most
specifically to relay concerns that Ms Chanthirakumar was not being
wholly open with staff about the extent of her distress. However, such
was the ward nurse’s anxiety not to breach patient confidentiality, the
conversation was not as meaningful or as productive as it might
otherwise have been.
It seems to me that nurses and doctors working in mental health
particularly, would benefit from a reminder of the difference between
absorbing (and, if appropriate, acting upon) concerns raised by a
patient’s relatives, friends, tutors etc., and divulging a patient’s private
details.
In addition, it may well be that a piece of self reflection has already
been undertaken by
for Ms
the mental health
Chanthirakumar, taking into account the fact that she took her own life
so soon after her discharge from a period of inpatient treatment, and
with her university being unaware of her own expectation that she
would be able to take her exams in August 2015. It seems that such
reflection might usefully inform future practice.
team caring
6
ACTION SHOULD BE TAKEN
In my opinion, action should be taken to prevent future deaths and I
believe that you and your organisations 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, by 11 April 2016. I, the coroner, may extend the period.
3
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 following.
HHJ Peter Thornton QC, the Chief Coroner of England & Wales
parents of Chentoori Chanthirakumar
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
interest. You may make
representations to me, the Senior Coroner, at the time of your response,
about the release or the publication of your response by the Chief
Coroner.
it useful or of
find
9
DATE SIGNED BY SENIOR CORONER
05.02.16
4
See every Prevention of Future Deaths report matching East London NHS Foundation Trust, 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.