Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0487, written 24 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 | 24 Jan 2019 |
|---|---|
| Reference | 2019-0487 |
| Deceased | Arun Viswambaran |
| Coroner | Sarah Bourke |
| Coroner area | Inner North London |
| Category | Suicide (from 2015) · Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | North East London NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
Text extracted from the PDF text layer. 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:
John Brouder
Chief Executive
North East London NHS Foundation Trust
The West Wing
CEME Centre
Marsh Way
Rainham
RM13 8GQ
1
CORONER
I am: Assistant Coroner Sarah Bourke
Inner North London
Poplar Coroner’s Court
127 Poplar High Street
London
E14 0AE
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 21 September 2018, Senior Coroner Mary Hassell commenced an
investigation into the death of Arun Viswambaran aged 27 years. The
investigation concluded at the end of the inquest on 9 January 2019.
The conclusion of the inquest was that Mr Viswambaran committed suicide.
The medical cause of death was:
1a dihydrocodeine and paracetamol toxicity
My short form conclusion was that “Mr Viswambaran took his own life at his
home on 18 September 2018”
4
CIRCUMSTANCES OF THE DEATH
Mr Viswambaran had recently started living with his partner in Tower Hamlets
but remained registered with his family GP at the Redbridge Surgery, 49
Windermere Gardens, Ilford, IG4 5BZ. On 16 July 2017, he saw his GP and
reported that he was depressed. His PHQ9 score of 19/27 suggested that he had
moderately severe depression. He denied thoughts of suicide or self-harm.
Following a discussion, he was prescribed Sertraline 50mg, given the crisis team
contact number and details of how to refer himself to the IAPT service. He was
reviewed on 3 August 2018 when he reported that he had not noticed much
improvement in his mood and that he had tried to contact IAPT but had not had
any response. It was decided that he would remain on Sertraline 50mg and
would have a further review in 3 weeks’ time. His family and friends noted that
he was engaging less with other people, his mood was lower and that he was
being increasingly critical of himself. Arun had a triage telephone call with the
IAPT service and was placed on the waiting list. He did not attend any further
GP appointments and would have run out of Sertraline in early September. On
18 September 2018, Mr Viswambaran told his partner that he was working a
night shift and would be spending the day at home. He resigned from his job by
email later that morning. In the early afternoon, he sent a number of text
messages which concerned his friends. When they were unable to make contact
with him, they asked police to break into the property. Mr Viswambaran was
found dead in the bath. A subsequent post-mortem examination found that he
had overdosed on co-dydramol tablets.
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) From the evidence of Mr Viswambaran’s GP,
, it
transpired that the waiting time for IAPT therapy is in the region of 12
weeks but could be up to 18 weeks. I am concerned that individuals may
experience a deterioration in their mental health pending an
appointment or disengage from mental health services due to the length
of waiting times for therapy.
2) Mr Viswambaran had problems making contact with the IAPT team by
telephone in order to arrange the initial triage telephone call. I am
concerned that this may discourage people from pursuing assistance
from the service.
6
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe you
and 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 22 March 2019. 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 Persons
(father)
I have also sent it to
London Coronial Area) who may find it useful or of interest.
and Senior Coroner Nadia Persaud (East
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.
Sarah Bourke
Assistant Coroner
24 January 2019
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