Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0176, written 6 May 2016. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 6 May 2016 |
|---|---|
| Reference | 2016-0176 |
| Deceased | Jack Susianta |
| Coroner | Mary Hassell |
| Coroner area | Inner North London |
| Category | Child Death (from 2015) · Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | East London NHS Foundation Trust · Homerton University Hospital NHS 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
Komang Jack SUSIANTA (died 29.07.15)
THIS REPORT IS BEING SENT TO:
1. Dr Kevin Cleary
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 3 August 2015, one of my assistant coroners, William Dolman,
commenced an investigation into the death of Jack Susianta, aged 17
years. The investigation concluded at the end of the inquest on 29 April
2016. At inquest, the jury made a determination that death arose as a
result of a drug related accident.
4
CIRCUMSTANCES OF THE DEATH
Jack was a 17 year old boy who suffered a drug related psychotic
episode after having taken cannabis and ecstasy at a music festival. He
was detained by police under s136 of the Mental Health Act and taken to
Homerton University Hospital at around 3am on Tuesday, 28 July 2015.
1
Following assessment, he was diagnosed as having suffered a substance
related psychosis, and was discharged soon after 7am with a plan for
follow up.
However, after discharge Jack’s condition deteriorated. His family
recognised this, but did not know how best to help him, other than to stay
close and offer love & support.
The following afternoon, Wednesday, 29 July, his family called police
again but, during the call, he left the family home by jumping through a
window. Police attended and he was deemed a high risk missing person.
During a line search, police officers saw him running towards a river.
One gave chase and nearly caught him, but Jack dodged and then
jumped in the river. He submerged and drowned.
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 consultant psychiatrist who assessed Jack on the morning of
Tuesday, 28 July, fully expected him to continue to improve. Whilst she
was concerned that he might take drugs again, she thought that he had
recovered from this psychotic episode.
However, she did not communicate to his family:
-
first and foremost, the fact that she expected him now to be free
from all psychotic symptoms;
- second, that any recurrence of these symptoms would be a cause
-
for significant concern and potentially immediate action;
thirdly, in exactly what circumstances professional help should be
sought on an urgent basis and how to go about this.
Jack’s family were very worried indeed about his condition. However,
because they had not been given the clinical expectation, they did not
know that they could/should take him back to hospital, even though he
had been discharged only hours before.
By the time they rang police that afternoon, Jack was on the point of
leaving the house. However, they had felt something was wrong from the
evening before. His brother had even trawled the internet looking for
appropriate advice.
2
I am aware that new systems have been put in place by the East London
Foundation Trust at Homerton University Hospital. The one point that I
would like most especially to bring to your attention is the need to
communicate clinical expectations (preceding return advice) to patients
and their families before discharge.
6
ACTION SHOULD BE TAKEN
In my opinion, action should be taken to prevent future deaths and I
believe that 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 by 11 July 2016. 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 following.
HHJ Peter Thornton QC, the Chief Coroner of England & Wales
Homerton University Hospital NHS Trust
Hackney Child Death Overview Panel
The Susianta family
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
interest. You may make
he believes may
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
06.05.16
3
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