Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0402, written 21 Dec 2018. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 21 Dec 2018 |
|---|---|
| Reference | 2018-0402 |
| Deceased | Cady Stewart |
| Coroner | Alison Mutch |
| Coroner area | Manchester South |
| Category | Suicide (from 2015) |
| 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 TO PREVENT FUTURE DEATHS.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO: The Chief Executive of Tameside
Clinical Commissioning Group (CCG
CORONER
{am Alison Mutch ,Senior Coroner, for the coroner area of South
Manchester
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 4" June 2018 | commenced an investigation into the death of Cady
James Stewart. The inquest concluded on the 14" December 2018 and
the conclusion was one of suicide
The medical cause of death was 1a) Combined drug toxicity
. Post-mortem found a fatal combination
of prescribed drugs in her system.
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 inquest heard that Cady Stewart's mother had died a few
months before from terminal cancer. Whilst her mother was on
palliative care she had been prescribed a significant amount of
opiate drugs. After her death the medication was not removed
by the nursing team and remained in Cady Stewart's
possession. It remained in her possession even though she
attempted to take her life immediately after her mother’s death.
She used that in combination with medication prescribed to her
to take her life.
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.
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date
of this report, namely by 8" February 2019. |, 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 namely cousin of the
deceased, who may find it useful or of interest.
| 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.
Alison Mutch OBE
HM Senior Coroner
21/12/2018
See every Prevention of Future Deaths report matching Suicide (from 2015), 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.