Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0178, written 1 Jun 2017. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 1 Jun 2017 |
|---|---|
| Reference | 2017-0178 |
| Deceased | Terry Latimer |
| Coroner | Paul Kelly |
| Coroner area | North Lincolnshire and Grimsby |
| Category | Community health care and emergency services related deaths · Suicide (from 2015) |
| 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.
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:
,
Director, Adults and Community Wellbeing,
North Lincolnshire Council,
Ashby Road,
Scunthorpe DN16 1AB
1
CORONER
Paul Kelly, Senior Coroner for the area of North Lincolnshire and Grimsby
2
CORONER’S LEGAL POWERS
I 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 2nd June 2016 I began an investigation into the death of Terry Stapleton Latimer who
died on 27th May 2016 by hanging. The investigation concluded with an inquest on 25th
May 2017
4
CIRCUMSTANCES OF THE DEATH
On 27th May 2016 the deceased was found dead by hanging at his home address. An
inquest determined he died by suicide. The deceased received inpatient care in local
psychiatric services between 18th April and 25th April 2016. On 15th May 2016 Police
persuaded him to attend A&E at Scunthorpe General Hospital following safety concerns.
The deceased did not wait to be seen.
A Safeguarding notification was generated by the attending Police Officer and submitted
through usual procedures on 16th May 2016.
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 safeguarding notice was not acted upon either at all or appropriately. In particular a
request accompanying the notice that the case be referred to Mental Health Services
was not complied with. Evidence indicates lack of clarity in understanding whether the
notice is just for information or should be followed up.
6
ACTION SHOULD BE TAKEN
1
In my opinion action should be taken to prevent future deaths and I believe you have the
power to take such action.
Namely a review with stakeholders (Police, A&E, mental health services) as to practices
and procedures for safeguarding referral of mentally disordered persons known to be a
threat to his or her own safety.
7
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report. I
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 Chief Coroner and to the following Interested
persons, namely the deceased’s 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 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.
9
Dated 1st June 2016 H.M. Senior Coroner.
2
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