Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0105, written 12 Apr 2018. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 12 Apr 2018 |
|---|---|
| Reference | 2018-0105 |
| Deceased | William Callis |
| Coroner | Anne Pember |
| Coroner area | Northamptonshire |
| Category | Care Home Health related deaths |
| 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.
REGULATION 28 REPORT ON ACTION TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: St Lukes Primary Care Centre Timken Way South Duston Northampton NN5 6FR CORONER lam Anne Mary Christine Pember, Senior Coroner for the coroner area of Northampton. 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 28/03/2017 | commenced an investigation into the death of William John Callis whose date of birth was 19/02/1954. The investigation concluded at the end of the inquest on 07/03/2018. The medical cause of death was:- 1a) Hanging CIRCUMSTANCES OF THE DEATH William John Callis was suffering from depression and sought help from his GP surgery in this regard. made an urgent referral to the Crisis Team on 10/02/2017 and he was seen that afternoon. He was later reviewed by the Mental Health team. He later was discharged from the urgent care and assessment team on 20/02/2017. On 14/03/2017 he was seen by Advanced Nurse Practitioner est the GP surgery. His depression and anxiety symptoms were raised sof referred him back to the Mental Health Team. This referral was not taken on. William John Callis later hung himself at his home address on 28/03/2017. During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths could 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 inquest it became clear that there was no specific instruction as to the correct procedure for a GP practice to adopt when making a referral to the Urgent Care and Assessment team. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you 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 7** June 2018. |, 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:-. | tti*“E represented by Lime Personal Injury as Assistant Director of Mental Health, Speciality Services & earning Disabili jorthamptonshire NHS Foundation Trust All GP Surgeries in Northamptonshire Similarly, you are 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. [DATE] [SIGNED BY CORONER] a 12 April2018 Xf, Deh
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