Prevention of Future Deaths reports · 2020
Regulation 28 report to prevent future deaths, reference 2020-0004, written 13 Jan 2020. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 13 Jan 2020 |
|---|---|
| Reference | 2020-0004 |
| Deceased | Annette Lewis |
| Coroner | Caroline Sumeray |
| Coroner area | Isle of Wight |
| Category | Hospital Death (Clinical Procedures and medical management) 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. General Manager for the National Trust on the Isle of Wight, Longstone Farmhouse, Mottistone, Isle of Wight, PO30 4EA 2. Mr Simon Bryant FFPH, 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 15th August 2019 I commenced an investigation into the death of Annette Jane Lewis, aged 55. The investigation concluded at the end of the inquest on 8th January 2020. The conclusion of the inquest was a short form conclusion as follows: “Open Conclusion.” The medical cause of death was found to be: 1a Severe Multiple Traumatic Injuries. 1b 1c II 4 CIRCUMSTANCES OF THE DEATH 1) Annette Jane Lewis was born on 13th May 1964. At the time of her death she was 55 years old and worked as an Artist. 2) On Tuesday 30th July 2019, Mrs Lewis and her husband went to bed, but Mrs Lewis became agitated and got up and started to bang her head against the 1 caravan wall. She became distressed, so her husband sought help from the 999 emergency number and was redirected to speak with the Crisis team. An ambulance was summonsed, but then Mrs Lewis returned to a calm state, and the ambulance was cancelled by 3) At around 2 a.m. that night Mrs Lewis complained to her husband of a tingling feeling in the side of her face, her arm and her hand. As they were both concerned by this development, took Mrs Lewis to the A&E department of St Mary’s Hospital, Isle of Wight NHS Trust. There, she requested a blood test to check for anaemia as she was concerned that due to her raw vegan and juice diet lifestyle, that she might be deficient in some vitamins and minerals. She was triaged by a nurse and assessed by a Middle Grade Clinician in the department and it was decided that she should see her GP about this issue the following week. No tests were undertaken, and returned home. Mrs Lewis was still restless and performed an enema upon herself and informed her husband that she felt like she was trying to pass a tumour and had lost a lot of blood, which could see on the bathroom floor. For the second time that night he summonsed an ambulance which took them back to the A&E department of St Mary’s Hospital, Isle of Wight NHS Trust. 4) Upon arrival, Mrs Lewis was again triaged, and seen by the same Middle Grade Clinician who had seen her approximately four hours earlier. She was fully examined, and a number of tests were carried out, but no abnormal findings were made – there was no evidence of any rectal bleed. In evidence, it was clear that the Clinician who had seen her twice and had two discussions with her found her to be odd, but not obviously mentally ill. He had not been informed about the initial episode of head-banging against the wall and he said he may have found that information relevant had he known about it during those two later consultations. Once again, Mrs Lewis was discharged by the A&E department to go home with her husband. According to her husband, Mrs Lewis was upbeat and happy that there was nothing seriously wrong. 5) Upon returning home, Mrs Lewis cancelled plans to see her mother and son that morning and took delivery of a grocery order. She made her husband something to eat and he fell asleep in a chair in the garden, as he was tired due to such an interrupted night. He last saw his wife around 11.30 a.m.. He woke up around an hour later and was concerned to discover that his wife was not around, and she had let the chickens out and locked the front gate. He began calling her on her mobile but she did not answer as she had already died. 2 6) It transpired that Mrs Lewis had gone up to Tennyson Down and had begun to behave very strangely. She was on her own and was witnessed by members of the public at around noon that day, to be in acute distress, talking to herself and screaming “Don’t take my baby” (her name for her dog who had died earlier in the year), as well as singing the song “I would do anything”. She had taken her top off previously, and then she removed all her other clothes so that she was completely naked. She then did a dance beside the edge of the cliff, causing the member of the public to fear for her safety and call the Police, before Mrs Lewis threw herself over the edge of the cliff with predictably catastrophic consequences. Her body was subsequently retrieved by HM Coastguard. She had left no note or explanation for her sudden actions. 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. The MATTERS OF CONCERN are as follows: – 1. I heard evidence from that there are no fences to protect the public from falling over the edge of the cliff at Tennyson Down, and moreover that there are no signs providing those in some sort of mental distress with the number for the Samaritans. Whilst I acknowledge that putting fences around the edge of the cliff would be a massive undertaking by the landowners, it may prevent a future death if those who are in extremis are reminded that there are people out there who are trained to assist them at that time. 2. Having just concluded a similar inquest involving a woman who threw herself from the top of Culver Cliff where I raised similar concerns with both the National Trust and the Director of Public Health who heads up the Suicide Prevention Group on the Isle of Wight, it seems appropriate that if consideration is being given by these organisations to better signage being implemented at the top of Culver Cliff, at the same time, consideration can also be given to making similar improvements at Tennyson Down. 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 9th March 2020. I, the Coroner, may extend the period. 3 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: 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 13th January 2020 4
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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