Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0457, written 31 Dec 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 31 Dec 2019 |
|---|---|
| Reference | 2019-0457 |
| Deceased | Joanna Orpin |
| Coroner | Caroline Sumeray |
| Coroner area | Isle of Wight |
| Category | Mental Health related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. 2. , General Manager for the National Trust on the Isle of Wight, Longstone Farmhouse, Mottistone, Isle of Wight, PO30 4EA , Director of Public Health, Suicide Prevention Group, Isle of Wight Council, Jubilee Stores, County Hall, Newport, Isle of Wight, PO30 1UD 1 CORONER I am Caroline Sarah Sumeray, Senior Coroner for the Coroner Area of the Isle of Wight. 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 1st March 2018 I commenced an investigation into the death of Joanna Sarah Louise Orpin, aged 42. The investigation concluded at the end of the inquest on 17th December 2019. The conclusion of the inquest was a short form conclusion as follows: “Joanna Sarah Louise Orpin killed herself.” The medical cause of death was found to be: 1a Multiple Traumatic Injuries. 1b 1c II 4 CIRCUMSTANCES OF THE DEATH 1) Joanna Sarah Louise Orpin was born on 19th January 1976. At the time of her death she was 42 years old and worked as a Senior Recruitment Consultant. 2) In late November 2017 Miss Orpin had developed a lingering cough and chest infection and visited her GP who prescribed her antibiotics. 1 3) She had two teleconsultations with a GP at her practice on 16th and 19th January. During the course of the latter one, it was clear that she was highly stressed, agitated and anxious, so her GP prescribed Diazepam for her severe anxiety. A further review was diarised for 22nd January. 4) At the consultation on 22nd January, it was clear to her GP that she was still very anxious and agitated and was not sleeping, so she was prescribed Mirtazepine and a referral was made to Primary Care “Improving Access to Psychological Therapies”. 5) Miss Orpin’s mother contacted the GP the following day (23rd January 2018) to say that her daughter was still struggling to sleep and remained anxious. 6) On 24th January 2018, Miss Orpin attended the GP’s surgery and was seen in an emergency appointment. The GP assessed her as being very anxious and she expressed many negative thoughts and a feeling of worthlessness. She had no active suicidal plans but had thoughts of not wanting to be there. Her presentation was both unkempt and agitated. The GP arranged for an urgent referral to the Hospital Mental Health Team due to her agitated depression deteriorating so significantly over a short period of time. A face-to-face assessment was booked for the following day with a Mental Health Nurse. Again, her presentation was described as being severely anxious, agitated and restless. She paced around the room as she spoke. The Nurse referred her on to the Home Treatment Team and arranged an appointment with a Consultant Psychiatrist the next day. Her medication had been increased to include Zopiclone and Quetiapine, but her presentation had not altered from agitated depression. 7) The Home Treatment team indicated that they planned to visit Miss Orpin daily to help her manage her mental health crisis. These visits commenced on 27th January 2018 except when Miss Orpin requested a family day with her partner and two young sons. They were interspersed with appointments to titrate her medication. Her agitated depression remained resistant to treatment. Miss Orpin’s presentation varied a little on occasion, and she had better days as well as days when she continued to feel deeply anxious and agitated. 8) By 7th February 2018, Miss Orpin had asked to reduce the Home Treatment Team’s visits to every third day. In reality, she declined visits over 5 consecutive days before agreeing to be visited again by the Home Treatment Team on 12th February 2018. On that occasion she was feeling very low; she was tearful and anxious. She didn’t believe that her medication was working, and she had 2 become stuck in a cycle of negative thinking. She had no suicidal plan or intent. She agreed to a visit from a Consultant Psychiatrist the following day. As with all her other visits from the Home Treatment Team, no risk of harm was identified, and she underwent a Mental State Examination and assessment of capacity. 9) The following morning, 13th February 2018, Miss Orpin woke up early and went downstairs to feed her sons breakfast and hot chocolate whilst her partner slept. She then told the children that she was going to go for a run, which is something she hadn’t done for a while. By the time her partner woke up she had gone and taken the car – something she wasn’t supposed to do whilst on these potent medications. 10) Miss Orpin’s partner immediately took their boys out to search for her. She was not at the local Tesco supermarket, and when he drove up to Culver Cliff, he did not see her vehicle there. Having dropped the boys with Miss Orpin’s mother, he heard that Miss Orpin’s car had now been located in the car park at Culver Cliff. (It was later discovered that she had stopped off to buy some cigarettes at a shop en route to Culver Cliff.) Miss Orpin’s partner immediately returned to discover a large police presence which Miss Orpin’s disappearance, as a vulnerable person due to her fragile mental state, had generated. 11) Amongst the Police personnel present was a dog handler whose dog tracked Miss Orpin’s scent approximately a quarter of a mile from the car park, where she had left her unlocked car, to a kissing gate in the main fence which runs along the length of the cliff edge. It was at that point that Miss Orpin’s scent could be detected no longer, and the logical inference was that she had crossed over the kissing gate and protective fence at that point. Later, her car keys and mobile phone were found and had been thrown approximately 5 metres from this point. It should be mentioned that the weather conditions on this day were atrocious with high winds which would have forced anyone back inland from the edge of the cliff, with cold rain coming in sideways. No trace of Miss Orpin could be found on that date. 12) Whilst Miss Orpin’s trainers were found at the base of the cliff at a later date, Miss Orpin’s body was not located until 18th February 2018 when she was found naked on mudflats at Bosham Quay, Chichester, West Sussex. 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. 3 The MATTERS OF CONCERN are as follows: – 1. I heard evidence from Inspector that there are at least 3 or 4 people per month who are found in a state of mental distress at Culver Cliff who require the assistance of the Police or other agencies to ensure their safety. 2. I was also informed that whilst there used to be signs at the top of Culver Cliff akin to those which are found at Beachy Head in East Sussex and the Itchen Bridge in Southampton which have wording such as “Suicidal? Despairing? Call Samaritans on [local number]”, these signs appear to no longer be present. (Since the Inquest, I have been provided with the following proof that these signs once existed from : https://www.alamy.com/culver-down- uk-07th-july-2018-a-samaritans-sign-on-the-edge-of-culver-cliff-on-the-isle-of- wight-uk-reads-talk-to-us-if-things-are-getting-to-you-posted-after-a-spate-of- suicides-from-the-same-spot-yachts-can-be-seen-passing-in-the-background- during-the-round-the-island-yacht-race-on-the-hottest-recorded-day-of-the-year- so-far-at-33-degrees-celcius-credit-matthew-blythealamy-live-news- image211378076.html ) 3. During the course of his evidence, Inspector told the Inquest that he had made recommendations for these signs to be displayed approximately 3 years ago, and he was aware that a Consultant Psychiatrist had made similar recommendations within the last 12 months. Concerns had been ventilated in relation to how many signs would be required and at what intervals. It was the opinion of Inspector that just a small number of strategically placed signs (perhaps in the car park, and at various intervals along the length of the fence as well as at places where it is easier to cross the protective fence at the kissing gate) would be adequate – in his words, “If they save just one life, then it would be worthwhile.” I agree with his views. 4. I also heard evidence from , a Consultant Psychiatrist at the Isle of Wight NHS Trust that he sits on a Suicide Prevention Group, and they had also tried to get these signs reinstated at the top of Culver Cliff, to no avail. 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, 4 namely by 11th February 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 the following Interested , Inspector , Persons: , , , the Isle of Wight NHS Trust. , 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. 9 H.M. Senior Coroner – Isle of Wight 31st December 2019 5
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.
7th March 2020 Mrs Caroline Sumeray H.M. SENIOR CORONER FOR THE ISLE OF WIGHT Coroner’s Office Seaclose Offices Fairlee Road Newport Isle of Wight PO30 2QS Dear Mrs Sumeray, RESPONSE TO REGULATION 28 REPORTS ISSUED IN REGARD TO MS A LEWIS AND MS J ORPIN - SUICIDE PREVENTION ON NATIONAL TRUST LAND ON THE ISLE OF WIGHT In your Regulation 28 reports issued as a result of the investigations in to deaths of Joanna Orpin and Annette Lewis dated 31 Dec 19 and 13 Jan 20 respectively, you requested a response from the National Trust as to what action could be taken to prevent a recurrence of these incidents. As you may be aware, the National Trust is the largest landowner on the island and currently has responsibility for just over 2,100ha. As an organisation, we take our role in safeguarding our visitors extremely seriously and will always seek to avoid accident, incident or injury wherever possible, but implicit in this is that we are also responsible for large areas of unsupervised open access public land with only a small team to manage it. Nationally within the Trust, we manage a number of areas which face similar challenges with attempted or completed suicide attempts, most notably in the Birling Gap and Beachy Head area and further east in the White Cliffs of Dover area. The teams at those sites have been dealing first hand with distressed individuals and their relatives for a number of years. I can confirm that a number of measures were already in place at Culver Down, including a total of seven Samaritans signs placed within the past few years. A schematic showing the locations of these signs is at Annex A. In addition, ‘dragons teeth’ (wooden bollards to prevent vehicle access) are in place opposite the exits from the car park and there is a ditch to ground vehicles approaching the cliff edge. There is also a barbed wire fence running the National Trust – Isle of WIght Longstone Farmhouse Strawberry Lane Mottistone PO30 4EA Tel: +44 (0)1983 741020 www.nationaltrust.org.uk President: HRH The Prince of Wales Chair of Regional Advisory Board for London and South East: Director for London and South East: Nicola Briggs Registered office: Heelis, Kemble Drive, Swindon Wiltshire SN2 2NA Registered charity number 205846 length of the cliff edge in which a vehicle became entangled during one attempt, but it is primarily a stock fence and it would not be economically viable or aesthetically appropriate to fence the several miles of coastline owned by the Trust. In direct response to your request, the following actions have been undertaken: 1. Engagement with Public Health Principal: Health and Wellbeing – We are due to have a meeting on Wednesday 18th March in advance of meeting with the groups listed below to discuss the island-wide Suicide Prevention Plan, how this might apply specifically to our land and how we can best support it. 2. Engagement with the Suicide Prevention & Intervention, Isle of Wight team. A meeting with 2020 to conduct site visits to both Culver and Tennyson Downs. from the group has been scheduled for Friday 3rd April 3. Engagement with the IOW Samaritans. is also due to attend the meeting listed above on 3rd April. 4. Sought feedback from the National Trust South Downs and White Cliffs teams. Regarding best practice and to learn from their experience. We have received detailed feedback from these teams and have their continued support whilst assessing what measures may or may not be suitable. 5. Engagement with the Police. To seek advice and guidance. Countryside Manager to speak to 6. Conduct a full internal review of our suicide prevention measures. Once all the above meetings are complete, we will conduct a full review of our measures and implement changes where appropriate. Should you require an update beyond this response, I will be more than happy to provide one. I strongly believe it is in the best interests of all concerned that we work together to assist those in distress and ensure help is there when needed. Yours sincerely, General Manager – Isle of Wight Annex: A. Map of existing Samaritans’ signage at Culver Down. 2 ANNEX A TO RESPONSE TO REGULATION 28 REPORT - MAP OF EXISTING SAMARITANS SIGNAGE AT CULVER DOWN
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