Prevention of Future Deaths reports · 2020
Regulation 28 report to prevent future deaths, reference 2020-0050, written 3 Mar 2020. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 3 Mar 2020 |
|---|---|
| Reference | 2020-0050 |
| Deceased | Shaun Turner |
| Coroner | Alison Mutch |
| Coroner area | Manchester South |
| Category | Alcohol, drug and medication related deaths · 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.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Secretary of State for Health CORONER lam Alison Mutch , Senior Coroner, for the Coroner Area of Greater Manchester South 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 INVESTIGATION and INQUEST On 2274 July 2019, | commenced an investigation into the death of Shaun Lea Tumer. The investigation concluded on the 31% January 2020 and the conclusion was one of Suicide. The medical cause of death was 1a) Drug toxicity on a background of bronchopneumonia CIRCUMSTANCES OF THE DEATH On 20th July Shaun Lea Tumer was found unresponsive at his home address a Dukinfield. Police investigations found there were no suspicious circumstances or evidence of 3rd party involvement. A number of notes addressed to family members were recovered. Toxicology showed that he had ingested a fatal amount of codeine. 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. — During the course of the inquest, evidence was given by Mr Turner's family that whilst they accepted that there had been attempted contact of him by mental health services he was worried about how long it would take him to be able to access appropriate mental health services and receive support. He was aware through previous contact with Mental Health services that there could be delays and when he missed a call from them, the impact of that in relation to accessing mental health services preyed on his mind. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you 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 28" April 2020. |, 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 namely EE wife of the deceased, who may find it useful or of interest. | 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. Alison Mutch OBE HM Senior Coroner 03.03.2020
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.
From Nadine Dorries MP
Parliamentary Under Secretary of State for Patient Safety,
Suicide Prevention and Mental Health
39 Victoria Street
London
SW1H 0EU
020 7210 4850
16th April 2020
Your Reference: 313362
Our Reference: PFD-1207916
Ms Alison Patricia Mutch
HM Senior Coroner, Manchester South
HM Coroner's Court
1 Mount Tabor Street
Stockport SK1 3AG
Dear Ms Mutch
Thank you for your correspondence of 3 March 2020 to Matt Hancock about the tragic
death of Shaun Turner.
I would like to begin by saying how sorry I was to read of the circumstances of Mr Turner’s
death and I offer my deepest sympathies to his family and those who loved him. I can
appreciate how distressing his lost must be.
Your report raises important concerns about access to mental health services and I would
like to provide assurance that the Government and the NHS are taking steps to ensure
that no one faces a long wait to access mental health support.
We have introduced the first ever access and waiting time standards for mental health
services, including standards for early intervention for people experiencing a first episode
of psychosis and accessing psychological and talking therapies. These are being met or
are on track for delivery. In addition, the NHS has committed to testing and rolling out
comprehensive waiting time standards for adults and children over the next decade.
We are expanding access to talking and psychological therapies and improving quality
through the Improving Access to Psychological Therapies (IAPT) programme1. Already,
over 1 million people a year are starting treatment and we are aiming to increase access to
psychological therapies for an additional 600,000 people with common mental health
problems each year by 2020/21. The NHS Long Term Plan2 commits to ensuring that an
additional 380,000 adults and older adults will be able to access NICE3-approved IAPT
services by 2023/24.
1 https://www.england.nhs.uk/mental-health/adults/iapt/
2 https://www.longtermplan.nhs.uk/areas-of-work/mental-health/
3 National Institute for Health and Care Excellence
In December 2019, 98.4 per cent of people who completed a course of IAPT treatment
waited less than 18 weeks to start treatment and 88.6 per cent waited less than six
weeks4.
The NHS Long Term Plan also commits to specific waiting times targets for emergency
mental health services which will take effect for the first time from 2020/21 onwards and
will align with the equivalent targets for emergency physical health services.
We recognise the need for people experiencing a mental health crisis to get the care that
they need quickly. Every local health service has now signed up to having a round the
clock community mental health crisis service by 2021, with people whose needs might be
escalating to crisis point able to self-refer in the same way they can for urgent physical
health care. More than £200million of national funding has been allocated to local areas to
transform urgent and emergency mental health care and provide new, alternative forms of
provision, such as safe havens and crisis cafes. An additional £140million will bolster
these services further from 2021 onwards.
We know that every suicide is a tragedy that has a devastating and enduring impact on
families and communities. In January 2019, we published the first Cross-Government
Suicide Prevention Workplan5, which sets out an ambitious programme across national
and local government and the NHS. It will see every local authority, mental health trust
and prison in the country implementing suicide prevention policies.
Finally, we are investing £57million in suicide prevention through the NHS Long Term
Plan. All areas of the country will see investment by 2023/24 to support local suicide
prevention plans and establish bereavement support services.
I hope this response is helpful. Thank you for bringing these concerns to my attention.
NADINE DORRIES
4 https://digital.nhs.uk/data-and-information/publications/statistical/psychological-therapies-report-on-the-use-of-iapt-
services/december-2019-final-including-reports-on-the-iapt-pilots-and-quarter-3-2019-20-data
5 https://www.gov.uk/government/publications/suicide-prevention-cross-government-plan
See every Prevention of Future Deaths report matching Alcohol, drug and medication related deaths, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.