Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0282, written 1 Aug 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 1 Aug 2019 |
|---|---|
| Reference | 2019-0282 |
| Deceased | Daniel Shorrocks |
| Coroner | Ian Arrow |
| Coroner area | Plymouth, Torbay and South Devon |
| Category | Child Death (from 2015) · Mental Health related deaths · Suicide (from 2015) |
| 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 Plymouth Torbay and South Devon NR REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Secretary of State for Education, Secretary of State for Health 4 CORONER | MARROW, Senior Coroner, Plymouth, Torbay and South Devon 2 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. http:/Awww. legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7, http://www. legislation .gov.uk/uksi/2013/1 629/part/7/made 3 INVESTIGATION and INQUEST Inquest detail Following an investigation commenced on the 8! day of January 2018 and Inquest opened on the 8" day of January 2018: Atan inquest hearing at Coroner's Court Derriford Park Plymouth on the 30" day of July 2019 heard before IAN MICHAEL ARROW Senior Coroner in the coroner’s area for Plymouth, Torbay and South Devon, the following findings and determinations were made: Name: Daniel Cameron SHORROCKS Medical Cause of Death: Multiple Injuries Conclusion: Took own life On 1 January 2018 at Berry Head, Torbay, Devon 4 CIRCUMSTANCES OF THE DEATH The deceased was born in Torbay on 3 September 2000. Before his birth Torbay Childrens Social Care had identified potential for his significant harm following his birth. He was known to the Police by September 2002 when he was found playing alone in a park. Reports were made to Torbay Childrens Social Care indicating that he had been neglected. At age five, consideration was given to long term care by Torbay Childrens Services. In June 2007 approval was given for a kinship care in Essex. This was brought to an end at short notice and he was returned to Torbay. He spent several years in various foster care and respite care placements. The precise number of placements could not be identified. In January 2010 he was made know to the Child Adolescent Mental Health Service following his jumping a river and expressing a wish to die. On 18 September 2017 the deceased's then foster carer became concerned for his welfare, having found. a note. The Police were notified. The deceased was located on a viaduct by the Police and taken to a place safety for assessment. He was referred to the Child Adolescent Mental Health Service Crisis Team. The Crisis Team subsequently closed his support/case. On 14 December 2017 he was accepted into the Torbay Autism Assessment Service. On 1 January 2018 the deceased told his then foster carer that he was going to visit a friend and would return at 7pm. The deceased visited his friend. The account of the investigating Police Officer is that he discussed ending his own life with the friend. At 7.01pm his foster carer received a text ‘Dead at Berry Head’. The deceased's jacket was located at the top of a cliff at Berry Head. His dead body was at the foot of the cliff. 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) | ask please that your Department reviews the availability of resources to those Local Authorities which have a high proportion of young people in care and disproportionately few qualified and experienced staff. (2) | would also ask your Department to review the integration of services between Local Authority Care Services, Adolescent Mental Health Services and Pastoral Care provided in education settings. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you as Secretary of State 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 26 September 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: Director of Childrens Services, Torbay Council; Chief Executive; Childrens Commissioner; Children Adolescent Mental Health Service / Devon Partnership Trust; the deceased's mother, for information; Mr Foster MP; Dr Woolaston MP; the Local Safeguarding Board; (where the deceased was under 18). | 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. Dated 4 August 2019 yy Signature.
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.
Bod 2) Nadine Dorries MP is Parliamentary Under Secretary of State for Mental Health, Department Department rence ne seen Suicide Prevention and Pationt Safety of Healt Social Care | for Education Michelle Donelan MP Parliamentary Under Secretary of State for Children and Families RECEIVED Your Ref: IMA/LH/CJ/46/18 Our Ref: PFD-1185555 17 JAN 2020 Mr Ian M Arrow _ TM GOnONES HM Senior Coroner, County of Devon : HM Coroner's Office 1 Derriford Park Derriford Business Park Plymouth PL6 5QZ Thank you for your correspondence of 1 August 2019 to Matt Hancock and Gavin Williamson about the death of Daniel Cameron Shorrocks. We are grateful for the additional time in which to reply. We would like to take this opportunity to say how deeply saddened we are about Daniel’s death. His loss, at such a young age and in such circumstances, is deeply upsetting and we offer our condolences to those who knew, loved and supported Daniel. Your Report raises two matters of concern. Firstly, you asked that we review the availability of resources to those local authority care services which have a high proportion of young people in care and disproportionately few qualified staff. We recognise the importance of addressing challenges in children’s social care and supporting local authorities to deliver quality children’s services. Every child growing up in care should have a stable, secure environment where they feel supported. Where a child cannot live at home, it is one of the State’s most important responsibilities to ensure that they are kept safe and flourish. Looked-after children should benefit from the care and support that every child is entitled to. We will review the care system to make sure all care placements and settings provide children and young adults with the support they need. The proposals in next year’s finance settlement will give local authorities a 4.4% real-terms increase in their Core Spending Power, which will rise from £46.2 billion in 2019-20 to £49.1 billion in 2020-21. The funding package for next year delivers significant extra resources to adult and children’s social care. This includes allocating a £1 billion additional grant on top of the existing social care package, which will continue at 2019-20 levels. In relation to the second matter of concern, you ask for a review of the integration between local authority children’s care services, child and adolescent mental health services (CAMHS), and pastoral care provided in education settings. It might be helpful to know that joint statutory guidance on the health and wellbeing of looked after children has been issued by the Department of Health and Social Care and the Department for Education'. The guidance is issued to local authorities, clinical commissioning groups (CCGs) and NHS England under sections 10 and 11 of the Children Act 2004 and they must have regard to it when exercising their functions. It aims to ensure that looked after children have access to any physical or mental health care they may need. The guidance is scheduled for review in 2020. In addition, the National Institute for Health and Care Excellence (NICE) and the Social Care Institute for Excellence (SCIE) issued a joint public health guideline in 2010 on ‘Looked-after children and young people’*. The guideline covers how organisations, professionals and carers work together to deliver high quality care, stable placements and nurturing relationships for looked after children and young people. The recommendations in the guideline set out how agencies and services can work collaboratively to improve the quality of life for looked after children and young people and timely access to appropriate health and mental health services. Commissioners are expected to have regard to NICE guidance when planning and commissioning services. I am advised that an update of the guideline is planned. 1 https://assets. publishing. service.gov.uk/government/uploads/system/uploads/attachment, data/file/413368/Promoting_th e health and_ well-being of looked-after_children.pdf ? https://www.nice.org.uk/guidance/ph28 We are taking steps to improve mental health support for children and young people and, in doing so, we have considered the needs of those more likely to experience mental health difficulties, including looked after children. Since the publication of the Five Year Forward View for Mental Health in 2016°, we have seen access to community treatment increase from approximately a quarter, to a third of those with a diagnosable mental health need from birth to 18 years of age. The NHS Long Term Plan’, published in January 2019, reaffirms NHS England’s commitment to improve children and young people’s mental health services beyond the Five Year Forward View. The Plan sets out priorities for improving mental health services for children and young adults (from birth to 25 years of age). This includes better crisis services through 24/7 provision of mental health crisis services that combine crisis assessment, brief response and intensive home treatment functions. The Government is prioritising the transformation of mental health services for children and young people and has confirmed its commitment to provide early support for children and young people’s mental health in response to the consultation, Transforming Children and Young People’s Mental Health Provision: A Green Paper’. Improving the join up between local health and education services is at the heart of this programme of work led by NHS England, the Department of Health and Social Care, the Department for Education and Health Education England. The new NHS funded Mental Health Support Teams resulting from the consultation, which will be established in 20-25 per cent of the country by 2023, are designed to work in and around schools and colleges to provide additional capacity to address the mental health needs of children and young people. These teams will deliver interventions for those with mild to moderate mental health issues, support education settings to develop whole school or college approaches to promote good mental health and help children and young people with more severe needs to access the right support by working with schools and colleges to provide a link to specialist NHS services. 3 https://www.england.nhs.uk/wp-content/uploads/2016/02/Mental-Health-Taskforce-F YF V-final.pdf 4 https://www.longtermplan.nhs.uk/ Ss https://assets. publishing service.gov.uk/government/uploads/system/uploads/attachment_data/file/728892/government- response-to-consultation-on-transforming-children-and-young-peoples-mental-health.pdf Finally, to further support the integration between schools and colleges, and local mental health services, over the next four years, from 2019 to 2023, the Department for Education-funded Link Programme will be made available to all areas and CCGs, and through them to every school and college (including alternative provision settings) and children and young people's mental health services in England. The Link Programme encourages better join-up and communication between education settings and specialist children and young people’s mental health services. This will help more children and young people get the right support when they need it and help prevent individuals falling between the cracks in provision or experiencing poor transition between services. We were very sorry to hear of this tragedy and hope this reply is helpful. Please do not hesitate to let us know if there is any further information which you require. NADINE DORRIES MICHELLE DONELAN
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