Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0025, written 17 Jan 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 17 Jan 2019 |
|---|---|
| Reference | 2019-0025 |
| Deceased | Mylon Sheppard |
| Coroner | Sean McGovern |
| Coroner area | Warwickshire |
| Category | Hospital Death (Clinical Procedures and medical management) 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 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:
1. Chief Executive - Coventry & Warwickshire Partnership Trust
CORONER
!am S McGovern, senior coroner, for the coroner area of Warwickshire
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.
3 | INVESTIGATION and INQUEST
On 5 October 2018 | commenced an investigation into the death of Mylon Sheppard 49
years old. The investigation concluded at the end of the inquest on 17 January 2019.
The conclusion of the inquest was suicide.
4 | CIRCUMSTANCES OF THE DEATH
Mr Sheppard hanged himself at his home and was found on 3 October 2018. He had
significant contact with the Trust from 5 June 2018
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. —
(1) Failure of any effective oversight of decisions made by duty workers.
(2) Failure to effectively manage waiting lists.
(3) Failure to have a clear process at the Day Hospital in respect of non attendance of
patients.
(4) Failure to ensure that family members are including are care planning (where the
patient is happy for that to happen).
(5) Failure to have a system in place that clearly identified GP boundaries and
geographical boundaries in respect of local mental health services to minimise the risk of
incorrect referrals to the wrong teams..
6 | ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and | believe you as Chief
am
COPIES and PUBLICATION
Executive of the 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 15" March 2049. {, 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,
i have sent a copy of my report to the Chief Coroner and to the following Interested
Persons (2 crother of Mylon Sheppard)
| 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.
P47" January 2019
Senior Coroner S McGovern 8 Wp jer
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