Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0404, written 11 Nov 2016. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 11 Nov 2016 |
|---|---|
| Reference | 2016-0404 |
| Deceased | Melanie Lowe |
| Coroner | Caroline Beasley-Murray |
| Coroner area | Essex |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | North Essex Partnership University NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
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.
ANNEX A REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: North Essex University NHS Foundation Trust 1 | CORONER lam Caroline Beasley-Murray, senior coroner, for the coroner area of Essex + 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 2 March 2016 | commenced an investigation into the death of Melanie Ellen Lowe. The investigation concluded at the end of the inquest on 9 November 2016. The conclusion of the inquest was that Melanie Ellen Lowe killed herself. The jury added a narrative conclusion — Melanie’s risk of self harm/suicide was not properly and adequately assessed and reviewed. Adequate and appropriate precautions were not taken to manage her risk of self harm/suicide 4 | CIRCUMSTANCES OF THE DEATH Melanie Lowe, a 41 year old lady had suffered from somatization disorder over a long period of time and was sectioned under s2 MHA in the Derwent Centre Harlow. On the morning of 2 March she was found unresponsive in her room and she was found to have a wad of tissues obstructing her airway. She died in Princess Alexandra Hospital Harlow later that day. Both the trust’s own Serious Incident Investigation report and the independent psychiatric report provided by an independent psychiatrist instructed by the court were highly critical of the care provided to Melanie in the time leading up to her death 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. — (1) The trust's action plan is very basic, lacking specific detail. Some elements are blank and there is an absence of supporting evidence. A far more rigorous action plan is required in an effort to prevent future deaths such as Melanie's. al 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and ! believe you and your organisation have the power to take such action. L 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 16th January 2017. |, 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 — solicitors for the family. | 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. 11 November 2016 Caroline Beasley-Murray
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
v Se § 06 JUL 2017 4 SM/SB/68 5 July 2017 Mrs Caroline Beasley-Murray HM Senior Coroner County Hall Seax House Victoria Road South Chelmsford CM1 1QH Dear Mrs Beasley-Murray NHS Essex Partnership University NHS Foundation Trust Trust Head Office The Lodge Lodge Approach Wickford Essex SS11 7XX Tel: 01268 739677 Fax: 01268 739675 Email: sally.morris@eput.nhs.uk Acting Chair: Janet Wood Chief Executive: Sally Morris As part of our Merger Governance Process, | am writing to set out the Trust's formal response to the Regulation 28: Report to Prevent Future Deaths, dated 11 November 2016, for which North Essex Partnership NHS Foundation Trust received following the Inquest into the Death of Melanie Lowe. | can confirm that the previous action plan has been updated with supporting evidence to provide assurance that actions have been taken forward. Please find enclosed a copy of the Action Plan, which | hope addresses all of your concerns. | can also confirm that the Trust will complete a further audit to ensure that all the actions identified have been embedded into practice. | would like to offer my condolences to the family of Melanie and | hope this response provides them, and you, with assurance that the Trust regarded this situation very seriously and has taken action to address the issues raised. Yours sincerely S27) iN. — SALLY MORRIS Chief Executive
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