Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0426, written 30 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 | 30 Nov 2016 |
|---|---|
| Reference | 2016-0426 |
| Deceased | Emma Timbrell |
| Coroner | Geraint Williams |
| Coroner area | Worcestershire |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths · Suicide (from 2015) |
| Organisation named | Herefordshire and Worcestershire Health and Care NHS 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.
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; 1. Worcestershire Health and Care NHS Trust 2. 3. CORONER | am Geraint Urias Williams, Senior Coroner, for the coroner area of Worcestershire 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. INVESTIGATION and INQUEST On 7" September 2016 I commenced an investigation into the death of Emma Louise TIMBRELL then aged 35 years The investigation concluded at the end of the inquest on 28 November 2016, The conclusion of the inquest was suicide on 28" September 2016 the medical cause of death being hanging . CIRCUMSTANCES OF THE DEATH the deceased had a significant mental health history and hanged herself at her home. 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 deceased was given an out of hours telephone number for use should her suicidal ideation increase. However she was known to have limited finances and there was a concern that she would not have been able to afford to make the telephone cal if 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, and consideration should be given to the crisis and out of hours telephone number being a freephone number so that those in need but without the finances are able to access emergency help without hindrance. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 25" January 2017 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 rt to the Chief Coroner and to the following Interested Persons ar | 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. Signed ZF = GU Williams RES dayof KEENE) H M Senior Coroner Dero
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