Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0129A, written 17 Apr 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 Apr 2019 |
|---|---|
| Reference | 2019-0129A |
| Deceased | Brian Goodman |
| Coroner | Sarah Bourke |
| Coroner area | Inner North London |
| Category | Community health care |
| 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.
Coroner ME Hassell HM Senior Coroner Inner North London REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Group Director of Housing Care & Support One Housing Group 100 Chalk Farm Road London NW1 8EH CORONER tam: Assistant Coroner Sarah Bourke Inner North London St Pancras Coroner's Court Camley Street London N1C 4PP CORONER’S LEGAL POWERS I 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 21 November 2018 Assistant Coroner Brittain commenced an investigation into the death of Brian Goodman (aged 76 years). The investigation concluded at the end of the inquest on 12 March 2019. The conclusion of the inquest was that: Mr Goodman hanged himself on 9 November 2018. The medical cause of his death was: 1a suspension |_| recorded a short-form conclusion of suicide. CIRCUMSTANCES OF THE DEATH Mr Goodman had a diagnosis of emotionally unstable personality disorder with depression. He had attempted to end his life on a number of occasions. A number of methods had been used in these attempts, including hanging. In 2016, he moved int ci iis which is managed by One Support. In addition to support from One Support, Mr Goodman was a regular user of services provided by MIND in Camden. Mr Goodman had frequent contact with One Support staff who noted that he had a tendency to ruminate about past events and would express thoughts of wanting to “end it all”. In May 2018, MIND employees became aware that Mr Goodman had tied a scarf around his neck with the intention of hanging himself but had not gone through with this. One Support staff were informed. The matter was discussed with Mr Goodman. The rail was moved from Mr Goodman’s wardrobe as it was recognised to be a potential ligature point. On 8 November 2018, MIND informed workers at One Support that Mr Goodman had told a volunteer that he bought a rope in order to hang himself. This was discussed with Mr Goodman who agreed that his room could be searched. No rope was found. On 9 November 2018, staff found Mr Goodman hanging from the door closing mechanism to his room during the morning welfare check. 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 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. — (1) Mr Goodman expressed thoughts of hanging himself in May and November 2018. He also had a history of attempting suicide by hanging. (2) Whilst Mr Goodman’s wardrobe rail was recognised to be an obvious ligature point and removed in May 2018, no steps were taken to change the door closing mechanism in his room which could also be used as a ligature point. (3) The same type of door closing mechanisms continue to be used in One Support properties. 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 15 June 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: EN daughter) | 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. 4M. CORO eT H LON Assistant Coroner 17 April 2019
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.
Lor NE oT ix HOUSING LIVING BETTER 8 July 2019 Head office 100 Chalk Farm Road London NW1 8EH Assistant Coroner Sarah Bourke Inner North London St Pancras Coroner's Court Camley Street Customer line: 0300 123 9966 London Reception: 020 7428 4190 N1C 4PP onehousing.co.uk Dear Sarah Bourke Regulation 28 Report to Prevent Future Deaths (Brian Goodman) We are in receipt of the report dated 17 April 2019 and apologise for the delay in responding as we did not receive the original correspondence. We note your concerns and confirm the following actions we are putting in place; e The door closing mechanisms referred to continue to be widely used in care and support services, not only run by One Housing. These are in place on fire doors. We will work with our property services division to look at alternative closures for fire doors in our schemes where there is a higher risk of suicide. We are not in a position to be able to guarantee that all our supported housing schemes will be fully anti-ligature as we have to balance this with our responsibility as a landlord in terms of fire risk. e We currently run Suicide Awareness Training every 2 months for our staff. We are now putting in place running Applied Suicide Intervention Skills Training (ASIST) which is more advanced for a group of staff across our range of services. e Both points are being actioned with immediate effect. Yours sincerely Group Director Health Care and Support One Housing Group Limited is a registered society under the Co-operative and Community Benefit Societies Act 2014. Registration number: 20453R. Homes and Communities Agency number: LH0171. Registered office: 100 Chalk Farm Road, London NW1 8EH.
See every Prevention of Future Deaths report matching Community health care, 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.