Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0217, written 14 Aug 2017. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 14 Aug 2017 |
|---|---|
| Reference | 2017-0217 |
| Deceased | Terence Pimm |
| Coroner | Caroline Beasley-Murray |
| Coroner area | Essex |
| Category | Police related deaths |
| Organisation named | Essex Partnership University NHS Foundation Trust · North Essex Partnership University NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
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: Essex Police EPUT Essex Community Rehabilitation Company CORONER | am Caroline Beasley-Murray, senior coroner, for the coroner area of Essex 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. [HYPERLINKS] INVESTIGATION and INQUEST On 30 August 2016 | commenced an investigation into the death of Terence Joseph Pimm. The investigation concluded at the end of the inquest on 21 April 2017. The conclusion of the inquest was a narrative conclusion CIRCUMSTANCES OF THE DEATH On 26 August 2016, Mr Pimm leapt from the 7" floor of the carpark at Southway Colchester. His death was confirmed there. At the time of his death he was wanted for failing to appear at court in the Metropolitan Police area. On 8 August he had been detained at Romford polic3e station under s136 MHA and taken to Goodmayes Hospital. On 25 August he met with his probation officer and mad3e threat6s to jump off a carpark. He was taken to A and E at Colchester Hospital, he was not ass3essed because he was under the influence of alcohol. He was collected by his mother and the next day he did not, as promised, hand himself into the police but went to the carpark. 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). Call handling and record-keeping at The Lakes 2). Call handling and record-keeping at the police custody suite 3). The sufficiency of guidance and training. Cont... . To police call handlers as to whether an individual is, objectively, at an “immediate” risk. . To mental health assessors as to the circumstances in which the input of family Members should be sought. . The sufficiency of information sharing and coordination between the police, hospital Trust and probation service. . Training/guidance for mental health clinicians in relation to persons who are subject to a warrant. The evidence pointed to a lack of understanding as to the effect of a warrant upon the clinician's ability to assess and treat. 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. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by the 8th November 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 — Family solicitors Leigh Day lam 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. 14 August 2017 Caroline Beasley-Murray Senior Coroner Essex
2 responses 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.
7 November 2017 SM/PR/BW/98 CONFIDENTIAL Mrs Caroline Beasley-Murray HM Senior Coroner Seax House, Coroner’s Court Victoria Road South Chelmsford Essex CM1 1QH 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: Chair: Professor Chief Executive: Sally Morris Dear Mrs Beasley-Murray | am writing to set out the Trust's formal response to the Regulation 28: Report to Prevent Future Deaths, dated 14 August 2017, which was issued following the inquest into the death of Mr Terence Pimm. Sadly, Mr Pimm died while he was a patient of the former North Essex Partnership University NHS Foundation Trust. This Trust was dissolved when it merged with another Trust on 1 April 2017 to form Essex Partnership University NHS Foundation Trust. | am the Chief Executive of this new Trust, but did not hold any position in the former North Essex Partnership University NHS Foundation Trust. | would like to begin by extending our deepest condolences to the family of Mr Pimm. We fully understand that this has been, and remains, an extremely difficult time. | hope this response provides them and you with assurance that the Trust regards this situation very seriously and is taking action to address the issues raised in the inquest. | have responded below to the matters of concern relating to the former Trust: e Call handling and record-keeping at The Lakes: All health-based place of safety calls are directed now through the new Trust's call centre. This means that all calls are recorded and documented on a call-log by trained call-handlers. All patients admitted to health-based places of safety have individual patient records detailing potential risks, assessment of presentation and copies of documentation from other agencies. Further work is continuing on electronic record-keeping processes in regard to this issue. « To mental health assessors as to the circumstances in which the input of family members should be sought: The new Trust has taken steps to reinforce to staff the importance of family involvement and ongoing communications. A detailed debrief in this respect was undertaken with the staff involved in Mr Pimm’s care. Additionally, audits on this issue are being undertaken via the new Trust's staff supervision process. e The sufficiency of information sharing and coordination between the police, hospital Trust and probation service: The information-sharing concordat has been reinforced. Additionally, the new Trust holds localised police liaison emergency care meetings and will ensure that the probation service is invited to improve information sharing in this regard. The new Trust has launched a new street-triage team in which mental health practitioners work together with dedicated police officers. We anticipate that this initiative will also help significantly to improve information-sharing and coordination between our services. e Training/ guidance for mental health clinicians in relation to persons who are subject to a warrant: A new flowchart is in place now for staff, which details clearly which actions to take in situations where people are subject to a warrant. Training on this is underway for all our staff working in mental health accident and emergency teams and mental health criminal justice teams. Please be assured that learning from Mr Pimm's death is being shared across the new Trust to help prevent the same issues arising again. Finally, | would like to reiterate my condolences once again to Mr Pimm’s family at this very sad time. | hope that this response goes some way to providing assurance that the Trust regards their toss very seriously indeed and is taking steps to address the issues raised during the investigation and the inquest. Yours sincerely SALLY MORRIS Chief Executive
PU ESSEX +54 POLICE SII Protecting and serving Essex FAO: HM Senior Coroner Our Ref: FS 1532/16 Caroline Beasley-Murray Your Ref: H.M Coroners Office 08 November 2017 County Hall, A Block Victoria Road South Chelmsford Essex CM1 1QH Dear Madam Terence Pimm (deceased): Report to Prevent Future Deaths In response to your Regulation 28 report to prevent future deaths dated 14" August 2017 | confirm as follows; Call handling and record-keeping at the police custody suite Essex Police have taken the following action; e The Essex Police switchboard operators have been instructed to refer telephone calls from the public concerning matters that do not concen a person in custody at the time of the call through to the Force Control Room (FCR) and not a custody suite. e Managers and staff working within custody suites have been advised that (i) only Essex Police personnel are to answer the telephones in custody, (ii) if non custody staff do answer the custody telephones they are to bring any relevant information concerning a detainee to the attention of custody staff for inclusion onto the custody record and (iii) any telephone calls received in custody which do not concern a detainee in that that custody suite at that time are to be transferred to FCR either as an emergency or non-emergency. This instruction is also set out in writing and placed within the custody suites. Essex Police Legal Department, Police Headquarters, PO Box 2, Springfield, Chelmsford, Essex CM2 6DA Telephone 01245 452603/5 Fax 01245 452246 [NOT PROTECTIVELY MARKED] The sufficiency of quidance and training to police call handlers as to whether an individual is, objectively, at an ‘immediate’ risk As part of their training FCR staff have a presentation on the threat harm and risk assessment process (known as THRIVE) to be applied for each ‘new’ call they receive and on receipt of new information concerning previous calls. In response to the issues raised during the Inquest touching upon the death of Mr Pimm this training has been supplemented with an additional section covering the issue of immediacy. The additional training highlights the nature of the risks that can arise when a call is received regarding a concern for welfare and the importance of addressing those concerns with appropriate immediacy, or if unsure to seek advice. The sufficiency of information sharing and co-ordination between the police, Hospital Trust and probation service Essex Police have taken the following action; e Essex Police has written to the Essex and Essex Community Rehabilitation Company concerning the outcome of the Inquest; “Given the recommendations, could we please ask you to consider implementing a process to ensure that if your staff become aware they are meeting with persons they know to be ‘wanted’, Essex Police are notified. In an emergency please call 999, but in all other circumstances please call 101. This will enable Essex Police to conduct a risk assessment, and take action as necessary in the hope of avoiding future deaths. “ e ‘Information Sharing Agreements, including Standard Operating Procedures, between Essex Police and our partners in Health are currently being developed. The final drafts were submitted to the Health lead on the 1% September and a meeting is scheduled to take place on 23 November 2017. One of the proposed Standard Operating Procedures includes provision for Health to make a request for information to Essex Police (or vice versa) “where Health Professionals are working with a patient or planning to work with a patient and it is identified that the police are likely to hold information relating to the patient, which would indicate they pose a risk of serious harm to: Themselves. Another patient. A member of staff.” The Regulation 28 Report to Prevent Future Deaths will be raised at the meeting to be held on 23% November in order to re-emphasise the importance of the proposed agreements. [NOT PROTECTIVELY MARKED] In addition to the above, mental health Street Triage cars are available to be deployed by the Essex Police Force Control Room in support of police officers dealing with mental health incidents. It is staffed by police officers and mental health professionals who operate a dedicated specialist response and advice role for mental health related incidents, including concern for welfare issues. The Triage unit can access the person's history via their mental health trust directly and without delay and if they are not in attendance this information can be passed to the police officers at the location. | hope you find this response satisfactory. Yours sincerely, s- - Force Solicitor NAT PRATECTIVEL ¥V MARKENT
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