Prevention of Future Deaths reports · 2020
Regulation 28 report to prevent future deaths, reference 2020-0175, written 18 Sep 2020. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 18 Sep 2020 |
|---|---|
| Reference | 2020-0175 |
| Deceased | Joseph Nihill |
| Coroner | Kevin McLoughlin |
| Coroner area | West Yorkshire (East) |
| Category | Suicide (from 2015) · Other related deaths |
| Organisation named | Leeds and York Partnership 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.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Secretary of State for Health, Matt Hancock CORONER I am Kevin Mcloughlin, Senior Coroner for the Coroner area of West Yorkshire (East) 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 8 April 2020, an investigation was commenced into the death of Joseph Francis Luke Nihill, aged 23. The investigation concluded at the end of the Inquest on 14 September 2020. The conclusion of the Inquest was one of suicide caused by toxicity. 4 CIRCUMSTANCES OF THE DEATH On Saturday 4 April 2020, Joseph Francis Luke Nihill, aged 23, was found dead on the sofa in the living room of his mother's home. He had left instructions not to touch his body as he had taken suicidal intent. to end his life. Farewell notes nearby confirmed his An examination of his computer later revealed he had been in contact with a gave him advice on methods of suicide. It was suggested he consider ' the most popular method here and it's easy to obtain (most of the time)". which , and told "It's 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) may be actively promoting a particular method of committing suicide and hence breaking the criminal law by assisting suicide. Consideration should be given to blocking their availability in the UK so as to negate this risk. (2) which enter discussions with troubled and vulnerable young men such as Joe Nihill serve to undermine the benefit of both the medical treatment provided to him and the constructive efforts of his family to restore his health. They have no social utility, but do have the potential to cause harm. (3) At a time when society is seeking to safeguard the mental health particularly of young men suffering from depression, it is counterproductive to permit such sites to bestow a legitimacy on self-harming behaviour. There is a foreseeable risk that other individuals will be drawn into a deteriorating cycle by discussing methods of ending their lives. 1 (4) It is harmful for potentially lethal substances to be made available and promoted could be as an effective method of killing oneself. In this case, Joe was told obtained for £8. Those supplying relatively small amounts of should be made aware of the implications of their trade. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe your organisation has 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 25 November 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 Persons: 1. The family of Mr Joseph Francis Luke Nihill 2. West Yorkshire Police, for the attention of 3. Mr- 4. The Coroners' Society, for the attention of Senior Coroner Ms Nadia Persaud 5. Leeds and York Partnership NHS Foundation Trust for attention of Ms 6. Metalchem Limited, 492 Falmer Road, Brighton, BN2 6LH Safeguarding and Domestic Violence Team, Safer Leeds 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 SIGNED BY SENIOR CORONER, KEVIN MCLOUGHLIN Kev~~~k- 18 September 2020 2
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