Sam Spooner

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS 

THIS REPORT IS BEING SENT TO: 

1. 

, Counsellor 

2.  The Senior Partner, Rope Green Medical Centre, Shavington, Crewe 

1 

CORONER 

I am Peter Sigee, assistant coroner, for the coroner area of Cheshire. 

2 

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. 

3 

INVESTIGATION and INQUEST 

On 4th September 2018 the Senior Coroner for Cheshire commenced an investigation into the death of Mr 
Sam Spooner, aged 20 years. The investigation concluded at the end of the inquest when I determined that 
Mr Spooner took his own life by suicide, suffocating himself by plastic bag and helium. 

4 

CIRCUMSTANCES OF THE DEATH 

Mr Sam Spooner died at Leighton Hospital on 31st August 2018, aged 20 years.   

Mr Spooner had last been seen alive at his home address at approximately 6:30pm on 31st August 2018 and 
he  had  last  spoken  to  a  family  member  by  telephone  at  approximately  6:40pm on  31st  August  2018.    Mr 
Spooner was found unresponsive in his bedroom having suffocated himself with the intention of ending his 
life at approximately 8:00pm on 31st August 2018.  Mr Spooner was taken to hospital by ambulance on an 
emergency basis with ongoing resuscitation efforts but these were unsuccessful. 

Mr Spooner had a known history of mental health issues dating back to at least December 2016 with previous 
concerns that he was at risk of suicide. Urgent mental health referrals were made by Mr Spooner’s GP on 
21st May 2018 and on 20th August 2018 following reports of active suicidal thoughts.  

On 30th August 2018 Mr Spooner attended a counselling session with a private counsellor and reported that: 
(1) he wanted to end his life; (2) he had attempted to do so on 26th August 2018; and (3) since then he had 
carried out further research and made further preparations to enable him to take his own life.  

Mr Spooner’s family  and GP  were  informed of this  conversation by the  counsellor but  no  adequate plans 
were put in place by the health care providers for Mr Spooner’s safety and the police were not contacted to 
inform them of the concerns for Mr Spooner’s mental health and of the real and immediate risk identified to 
Mr Spooner’s life. 

There were missed opportunities to provide additional care and support to Mr Spooner when he was known 
to be at real and immediate risk of suicide; it was not possible to determine whether this additional care and 
support would have prevented Mr Spooner’s death. 

1 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 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 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)  There  was  a  lack  of  multi-agency  information  sharing,  co-operation,  co-ordination  and  effective 

communication both within and between health care providers which meant that: 

a)  The  private  counsellor  who  provided  treatment  to  Mr  Spooner  did  not  have  adequate  information 
from other health care providers as to his medical/mental health history, diagnosis and treatment by 
other healthcare professionals. 

b)  There was a failure to adopt an effective multi-agency approach to the care for Mr Spooner from 20th 

August 2018 when it was known that he was actively considering ending his life. 

c)  There was a failure to adequately intervene from 30th August 2018 when it was known that: (1) Mr 
Spooner had recently attempted to take his life; and (2) Mr Spooner had subsequently undertaken 
additional research and made further preparations to enable him to do so. 

2)  There  was  an  excessive  and  unreasonable  reliance  placed  upon  Mr  Spooner’s  family  by  health  care 
providers to keep him safe when those providers knew that Mr Spooner’s family were not in a position to 
do so.   Health care providers lacked awareness of and/or failed to  adequately  involve  other agencies 
who may have been able to keep Mr Spooner safe, for example the police who may have been able to 
exercise their powers under section 136 of the Mental Health Act 1983 to take Mr Spooner to a place of 
safety. 

6 

ACTION SHOULD BE TAKEN 

In  my  opinion  action should be taken to prevent future deaths and  I  believe  you and/or  your organisation 
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 3rd January 
2020. I, 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. 

8 

COPIES and PUBLICATION 

I have sent a copy of my report to the Chief Coroner and to Mr Spooner’s family.  I have also sent it to the 
Cheshire & Wirral Partnership NHS Foundation Trust, the Royal College of General Practitioners  and the 
British Association for Counselling and Psychotherapy who may find it useful or of interest. 

I 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. 

8th November 2019                                          

2

1 6 DEC 1019 

British Association for
Counselling and Psychotherapy

BACP House 
15 St John 's Business Park 
Lutterworth, Leicestershire
LE 17 4 HB 

bacp@bacp.co.uk 
Call 01455 883300 
www.bacp.co.ul< 

bacp l 

counselling 
changes lives 

Mr Peter Sigee 
Assistant Coroner 
Office of Her Majesty's Coroner 
West Annexe 
Town  Hall 
Sankey Street 
Warrington 
WAl lUH 

12th December 2019 

Dear Mr Sigee 

The late Sam Spooner 

Thank you  for sending a copy of your Regulation  28 following the death of Sam  Spooner.  I was very saddened 
to read  of the circumstances of Mr Spooner's death . 

I wanted to contact you to outline some of the barriers our counsellors face  in  relation to information-sharing 
when they are in  private practice and  outside of any statutory system.  My sincere apologies if you  are aware 
of these difficulties already. 

Counsellors and psychotherapists working in  private settings are,  in  providing therapeutic services,  working on 
the basis of a voluntary contract between the client and themselves.  The  relationship does  not sit within the 
NHS or statlJt0r-y framework and  is-very-much a private-arrangement -between the elier-it -ar-id  13-r-a€titiooer:-The-
practitioner relies very much on the disclosure made by the client as they have  no right to access or store 
medical records .  In  relation to contracting,  most contracts guarantee confidentiality other than in the event of 
risk of harm to self or others {with additional considerations around specific legal  requirements, such  as those 
relating to anti-terror legislation, for example). This  puts a very heavy weight of responsibility on the 
practitioner in  relation to the client's wellbeing.  In this case,  the counsellor did contact the family and GP,  but 
I note that this and  other actions undertaken by healthcare providers was  not sufficient to avoid the death of 
Mr Spooner. 

The  British Association of Counselling and  Psychotherapy has  published a range  of guidance for its members in 
working with suicidal clients and  managing the risk of suicide.  These are available for our members to 
download from our website.  I will pass  your report onto our Professional Standards Department for 
consideration and  review as to whether it might be  possible to strengthen any current guidance in  light 
of these distressing events. 

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T +44 (0)333 320 2220   F +44 (0)333 320 4440  www.dwf.law 

Your Ref: 

Our Ref: 

PS/LR/15863/CR  

TSELL-PETERS/2022854/257 

Please quote this when replying 

Date: 

Please ask for: 
Ext: 
Direct Dial: 
E-mail: 
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31 January 2020 

498869 
+44 20 7280 8869 
@dwf.law 
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Mr Peter Sigee 
Assistant Coroner for Cheshire  
HM Coroner's Office for Cheshire  
West Annexe  
Town Hall  
Sankey Street  
Warrington  
Cheshire WA1 1UH  

By email only  

Dear Mr Sigee 

Inquest into the death of Sam Spooner 

I act for Mrs 

 upon instructions from her Insurers and have been instructed in this matter since 

you issued your Report into Preventing Future Deaths (dated 8.11.19).  I have been asked to assist Mrs 

with a response to your Report and, in particular, your concerns as below:- 

1)  There  was  a  lack  of  multi-agency  information  sharing  cooperation,  coordination  and  effective 

communication both within and between healthcare providers which meant that: 

a) 

The  private  counsellor  who  provided  treatment  to  Mr  Spooner  did  not  have  adequate 

information from other health care providers as to his medical/mental health history, diagnosis 

and treatment by other healthcare professionals.   

b) 

There was  a failure to adopt an effective  multi-agency  approach to the care for Mr Spooner 

from 20 August 2018 when it was known that he was actively considering ending his life.   

c) 

There was a failure to adequately intervene from 30 August 2018 when it was known that: 

i) 

ii) 

Mr Spooner had recently attempted to take his life; and  

Mr  Spooner  had  subsequently  undertaken  additional  research  and  made  further 

preparations to enable him to do so.   

2) 

There was an excessive and unreasonable reliance placed upon Mr Spooner's family by health care 

providers to keep him safe when those providers knew that Mr Spooner's family were not in a position 

to do so.  Health care providers lacked awareness and/or failed to adequately involve other agencies 

who may have been able to keep Mr Spooner safe, for example the police who may have been able to 

exercise their powers under section 136 of the Mental Health Act 1983 to take Mr Spooner to a place 

of safety.   

68592294-1 

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 Mr Peter Sigee 

31 January 2020 

You have asked that any response from Mrs 

 must contain details of actions taken or proposed to be 

taken, setting out the timetable for action.  Otherwise, we must explain why no action is proposed.   

It may be helpful if I set out some of the factual background to this matter.  Mrs 

 was unrepresented at 

this  Inquest  and  this  is  the  only  inquest  which  she  has  ever  attended.    She  works  entirely  privately  as  a 
psychotherapist  and  as  a  private  practitioner,  never  has  access  to  clients'  clinical  records,  detailed  (or 

sometimes any) mental health history or any other psychiatric evaluations or input.  In this case, the situation 

was even more difficult because Mrs 

 had only seen Mr Spooner twice, on 21 August 2018 and then on 

30 August 2018.   

It was Mr Spooner's mother who arranged for Mr Spooner to have private counselling with Mrs 

. She 

understood that Mr Spooner's mother did not consider that the input he was receiving from the NHS was helping 

him.  As  to the nature of the  input  which  Mr  Spooner  was receiving from NHS  Mental Health  Services, Mrs 

 had no information whatsoever, nor did she have any direct access to Mr Spooner's GP or any records 

of his treatment, either GP or mental health.   

In  these  circumstances,  any  information  which  Mrs 

  had  in  relation  to  Mr Spooner  was  taken  either 

directly from him or from his mother, to whom she spoke over the phone when she first made contact and with 

whom she also had some text dialogue.  The priority for Mrs 

 in these two initial sessions was to establish 

a rapport with Mr Spooner, but the therapeutic process is just that and this was the beginning of a process in 

which she hoped to establish a relationship with, and hopefully help, Mr Spooner.   

In the initial session, Mr Spooner made it clear that he did not want to be there. Mrs 

 found it difficult to 

engage with him, which meant that taking any information from Mr Spooner in those circumstances was very 

difficult indeed.    

Mrs 

 shares the Coroner's concerns about the outcome in this case and was extremely saddened to 

hear that Mr Spooner had indeed committed suicide the day after she saw him.  Mrs 

 was unaware of 

the extent of Mr Spooner's interaction with NHS Mental Health Services until she heard the evidence herself at 

the Inquest.  She has taken the opportunity to investigate in some considerable detail the options available to 

her as a private  psychotherapist in these circumstances.   It should be made clear that this is not a situation 

which Mrs 

 has encountered in the past.   

She has spoken to other private psychotherapists and her Clinical Supervisor about their respective practices.  

Mrs 

 always asks clients whether they have ever been under Mental Health Services, but she has now 

amended her assessment and consent forms (which are attached) so that she asks more particular questions 

about previous psychiatric history.  It is also the case that NICE issued guidelines on 10 September 2019 (i.e. 

after Mr Spooner's death) in relation to multi-agency suicide prevention partnerships and Mrs 

 has both 

considered those guidelines and thought about how she might implement some changes in her practice, both 

as a result of those guidelines and as a result of this case.  Mrs 

 has included a specific question on her 

consent form, if the client indicates that they have been under the care of a mental health practitioner, to ask for 

the client's consent to contact that mental health practitioner.   

Her intention in so doing is to establish contact with the NHS Mental Health Service, where relevant, in order 

that she has the ability to have some dialogue with that professional if needs be.   

68592294-1 

2 

 Mr Peter Sigee 

31 January 2020 

Mrs

 has also made extensive investigations locally to ascertain what the options might have been which 

were open to her on 30 August 2018 to secure further support for Mr Spooner .  Mrs 

 has found some 

notes  from  a  public  engagement  event  between  March  and  May  2018  which  outlines  the  provision  of  Adult 

Mental Health Support Services in Macclesfield, principally via the Millbrook Unit.  She has also spoken with as 

many contacts as she can within the local Mental Health Services and has ascertained a number of telephone 

numbers for crisis home treatment teams in her immediate area, including the following: 

  The Congleton Crisis Home Treatment Team, although this is not an out of hours service; 

  The Out of Hours Mental Health Support Service for East Cheshire, based in Macclesfield, which is open 

from 5pm to 9am; 

  The Community Mental Health Team in Macclesfield; 

  The Crewe Out of Hours Psychiatry Service.   

Mrs 

 considers that she is now much more informed about  local mental  health services and, should 

these events arise again, she would be in a better position to deal with a similar scenario.   

In terms of the engagement with the GP, Mrs 

 believes that it was appropriate to contact the GP who is 

the route into an NHS Mental Health Services referral. She now appreciates that there may be circumstances 
in which the involvement of the police would be appropriate, given their powers under the  Mental Health Act.  

Mrs 

 has of course taken on board the Coroner's indications in this regard and does bear in mind that, 

if there were a question of an immediate danger to someone's life because of suicidal ideation, contacting the 

police may also be an appropriate course of action. 

Finally, in terms of a practical example of changes in her practice, Mrs 

 has recently dealt with a suicidal 

client  and,  on  this  occasion,  in  fact  drove  the  client  to  her  GP  practice  herself  because  of  her  particular 

circumstances.  She also engaged directly with the Community Mental Health team, with the client's consent, 

as well as with the GP's surgery to request a referral for a further Community Mental Health assessment. Much 

of how she dealt with this client was informed by lessons learned from Mr Spooner's case. 

We trust this this is of assistance to the Coroner in response to the report but would be of course willing to assist 

further if the Coroner requires any further information. 

Yours sincerely 

Head of Healthcare Litigation & Healthcare Sector 

DWF Law LLP 

68592294-1 

3 

 
  
 
 Name: 

Address: 

D.O.B: 

Contact Number: 

Special needs: 

Relevant Medical Considerations: 

Emergency Contact Person/ Number: 

GP: 

Have you accessed 
counselling/psychotherapy before Yes / No? 
If yes, when was this?: 

Are you currently accessing a mental 
health provider? Yes / No? 

If yes, do you agree to me contacting your 
provider to make them aware you’re 
accessing my counselling service? Yes / No 
Please complete the additional consent 
form. 

What went well?: 

What was not useful? 

What are you hoping to gain from counselling? 

What are your current goals? 

What questions do you have? 

The above information is correct, and I can 
access or amend it when necessary. 

The above information is to aid the process 
of counselling supervision and in some 
cases multi agency working where 
appropriate. 

Signed Client……………………………………………… 

Signed Counsellor……………………………………… 

Date……………………………………………………………. 

Date………………………………………………………….. 

Revised Dec 2019 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Consent to Share Information Form 

CMG Counselling –
set for dealing with personal information outlined in our signed confidentiality agreement, privacy 
statement; and in line with the ethical framework of the British Association of Counsellors and 
Psychotherapists (BACP).  

 will comply with relevant confidentiality legislation standards 

I,
 will contact your current mental healthcare provider / professional to make them 
aware I am working with you in a private counsellor capacity. This will allow a communication line 
to be opened in the best interest of you, the client. 

Your informed consent for the sharing of information will be sought and respected in all situations 
unless it is unsafe or impossible to gain consent or consent has been refused, and, 
without information being shared, it is anticipated you pose a risk to your own or public health or 
safety. 
 
 

Consent to Share Information Form 

Primary Purpose Consent 
The  primary purpose of this form has been explained to me and I consent to the sharing of my 
personal information to assist in achieving the primary purpose.  

YES 

NO  

Proposed Use and Disclosure of my personal information 
I confirm that the following service(s) listed below is/are whom I am currently a patient of and 
relevant information about me may be forwarded to the agency(s) that provide these services in 
order that I receive the best possible service. 

Service Type 

Name of Agency 

Type of Information (including limits as applicable) 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Written Client Consent                                         Or 

Verbal Consent 

Record of Client Consent 

My private counsellor has discussed with me how and why 
certain information about me may need to be provided to other 
multi agency service providers. 

I understand the recommendations and I give my permission 
for the information to be shared as detailed above. 

Signed: 

Date:       /    / 

Signed by: Client 

Name: 

Witnessed: 

  Workers Use Only 

Verbal consent should only be used where it is not practicable 
to obtain written consent. 

I have discussed the proposed referrals with the client or 
authorised representative and I am satisfied that they 
understand the proposed uses and disclosures and have 
provided their informed consent to these. 

Signed: 

Name (Worker): 

Date:         /    / 

Position: 

To ensure the client is able to make an informed decision about consent to the disclosure of their information, 
(tick when completed) 

1.  Discuss with the client the proposed information to be disclosed to their healthcare 

professional/provider

2.  Explain that the client’s information will only be released if the client has agreed and advise  

that services will still be provided even if the client does not want information 
disclosed.

3.  Explain that information will be shared without consent if there is a serious threat to the health or safety of 

person(s), to report illegal activity or is required under 
law.