Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0339, written 23 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 | 23 Jun 2017 |
|---|---|
| Reference | 2017-0339 |
| Deceased | Andrew Codling |
| Coroner | Ian Pears |
| Coroner area | Bedfordshire and Luton |
| Category | Community health care and emergency services related deaths · Suicide (from 2015) |
| Organisation named | East London 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.
for Bedfordshire and Luton REGULATION 28 REPORT TO PREVENT FUTURE DEATHS I THIS REPORT IS BEING SENT TO: The Chief Executive East London NHS Foundation Trust Corporate Headquarters | 9 Alie Street i London. E1 8DE CORONER | am IAN PEARS, Acting Senior Coroner, for the coroner Area of Bedfordshire & | _ Luton | 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 5 December 2016 | commenced an Investigation into the death of | ANDREW STUART CODLING aged 39. The investigation concluded at the end of the Inquest on 18t June 2017. The Conclusion of the Inquest was ‘SUICIDE’. The medical cause of death was: 1 | : l(a) Hanging CIRCUMSTANCES OF THE DEATH On the 26" November 2016 the Deceased was found hanging at Old Warden | i Tunnel Woods near Cardington, Bedfordshire. He had had one previous suicide | attempt and was under the care of the Biggleswade Community Health Team at the time of his death. if | CORONER’S CONCERNS I 4 Senior Coroner, The Court House, Woburn Street, AMPTHILL, Bedfordshire, MK45 2H1X Tel 0300-300-6559 | Fax 0300-300-8267 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 last call from the Community Health Team to the deceased’s mobile went to voice mail. It reportedly said “...it is 3.57pm [Friday] now and | | am leaving the office at 4.00pm. You have literally 3 minutes to call me, | otherwise , call me Monday if you still need something”. (2) That call was in response to a call by the deceased. (3) That call missed the opportunity to re-inforce the fact that there were other means of help should the deceased require it, including the crisis numbers already provided by the Service. (4) Reminding the deceased that there was provision to provide support before Monday morning may have been all the deceased required to avoid taking the decision to hang himself particularly, bearing in mind it was the deceased who had initiated the call i 16 | ACTION SHOULD BE TAKEN i i | In my opinion action should be taken to prevent future deaths and | believe East London NHS Foundation Trust 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 7 August 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. 8 | COPIES and PUBLICATION \ 1 | have sent a copy of my report to the Chief Coroner and to the following : Interested Persons: Paula Codling. | am also under a duty to send the Chief Coroner a copy of your Response. Senior Coroner, The Court House, Woburn Street, AMPTHILL, Bedfordshire, MK45 2HX Tel 300-300-6559 | Fax 300-300-8267 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. Dated 23rd June 2017 /) fi IAN PEARS Acting Senior Coroner Bedfordshire & Luton Senior Coroner, The Court House, Woburn Street, AMPTHILL, Bedfordshire, MK45 2HX. Tel 0300-300-6559 | Fax 0300-300-8267
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.
East London NHS Foundation Trust Please respond io: Associate Director of Legal Affairs Trust Headquarters 9 Alle Street London E1 8DE Telephone: 020 3738 7253 4" August 2017 Acting Senior Coroner lan Pears - The Court House Woburn Street Ampthill Bedfordshire MEAS 2HX ip ee, Dear Inquest touching upon the death of Andrew Codling This is a formal response to your Regulation 28 Report dated 23° June in which you sei out your concerns relating fo the care Mr Codling received fram East London NeiS Foundation Trust, Your concems related specifically to the handling of a telephone call made by a member of staff at the Community Mental Health Team (CMHT) to Mr Codling. The call had been in response to a message left by Mr Codiing on the mobile phone of the member of staff. The call was returned the same day, a Friday afternoon. As Mr Codiing nad net answered the call ihe member of staff lefl a voicemail message asking Mr Cadling to call him back within the next few minutes or the matter would be dealt with on Monday. You were concerned that the member of staff had missed the opportunity to reinforce thal there were other means of heip should Mr Codling require it. in response to the concerns raised, a new protocal has been developed and implemented within the CMHTs. The protocal provides guidance to staff in relation to ihe use of mobile phones in communication with services users. Where a member of siaff provides a service user with their mobile phone number an explanatory letter is new pravided. This incluces information om who can be contacted should the call not be answered, depending on the nature of the call and what assistance is required. Chair: Maris Gabrie! Chief Execulive: Dr Navina Evans The Protocol also provides clear guidance to staff when responding to messages from service users, in the event the service user does not answer the call. The Proiocol requires staff to leave a message providing relevant information on who to call in the event they require urgent support (ie Duty Worker, Crisis Team or ARE) and provide the relevant telephone numbers. This will erisure that in similar circumstances service users will be clear that there are other options available to them should their care coordinator not be available. i hope that the action taken provides you with assurance thal the Trust has taken appropriate action and that your concern has been adequately addressed. if you de require any further information please do not hesitate to contact me. Yours faithfully Dr Kevin Cleary Chief Medical Officer Chain Marie Gabriel Chief Executive: Dr Navina Evans
See every Prevention of Future Deaths report matching East London NHS Foundation Trust, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.