Prevention of Future Deaths reports · 2020
Regulation 28 report to prevent future deaths, reference 2020-0250, written 24 Nov 2020. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 24 Nov 2020 |
|---|---|
| Reference | 2020-0250 |
| Deceased | Sharon Kelly |
| Coroner | Caroline Beasley-Murray |
| Coroner area | Essex |
| Category | Suicide (from 2015) · Mental Health related deaths · Emergency Services 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.
ANNEX A REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. EEAS 2. Essex Police 3. EPUT 1 CORONER I am Caroline Beasley-Murray senior coroner, for the coroner area of Essex 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 27 June 2019 I commenced an investigation into the death of Sharon Louise Kelly aged 44 years old. The investigation concluded at the end of the inquest on 12 November2019. The conclusion of the inquest was Sharon Louise Kelly killed herself. The contributing factors were as follows:- • The timing of the Mental Health Act assessment was inadequate • Failure to initiate the risk assessment upon arrival at the property by the EEAS • Widespread insufficient communication between all services. including medical cause of death and short-form conclusion or narrative conclusion summarised]. The medical cause of death was 1a) hanging 11) alcohol and multiple drug overdose 4 CIRCUMSTANCES OF THE DEATH Ms Kelly had a long history of mental health and alcohol problems with frequent suicide attempts. She informed a family member that she would kill herself on the anniversary of her baby son’s death. The ambulance attended her property but did not enter, awaiting police attendance which was delayed. When, eventually the services entered the property Ms Kelly was deceased. 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. – • Whether there is sufficiently clear training at EEASin relation to (1) identifying 1 relevant flag markers to ensure police attendance ata property where appropriate and 2) communicating relevant information from relevant records to ambulance crews to ensure that dynamic risk assessments take place on the basis of all relevant information (in light of decision making and delays on 27 June 2019) • Whether lines of communication and the modus operandi between EEAS and Essex Police are sufficiently clear in relation to a potential joint attendance at a property where there is a risk marker (given the delays on 27 June 2019) • Whether there is sufficient clarity in the training for Essex Police Comms Officers as to the circumstances in which a blue lights response should be mandated (in light of the evidence of Insp June 2019) as to the response on 27 • Whether EPUT can review its arrangements for convening an urgent MHS assessment, in conjunction with social services. (in light of the jury’s findings with regard to the MHA assessment in June 2019) 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe your organisations 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 8th January 2021. 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 who may find it useful or of interest. ECC Social Services I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any other person who I believe may find it useful or of interest. 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. 9 [DATE] 24 November 2020 Caroline Beasley-Murray REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (2) 2
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.
15th December 2020 Private and Confidential Caroline Beasley-Murray Area Coroner Coroner’s Office Seax House Victoria Road South Chelmsford CM1 1QH Dear Mrs Beasley-Murray, Patient Safety Incident Management Team The Lodge Lodge Approach Wickford Essex SS11 7XX Tel: I am writing to set out the Trust’s formal response to the report made under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013, dated 25th November 2020, which was issued following the inquest into the death of Sharon Kelly. I would like to begin by extending my deepest condolences to the family of Ms Kelly. This has been an extremely difficult time for them and I hope that my response provides the family, and you, with assurance that the Trust takes their loss seriously and has taken action to address the issue of concern raised in your report. In response to the matter of concern regarding whether EPUT can review its arrangements for convening urgent Mental Health Act Assessments in conjunction with social services, I can confirm that a strong collaborative relationship exists between EPUT and ECC which reflects, develops and undertakes continuous improvement initiatives. In response to your concern, the Trust’s Associate Director for Social Care and the ECC Service Manager for Mental Health have jointly reviewed the current processes and have identified the following actions to be implemented by the Trust: 1. The Trust will ensure that referrals for urgent MHA assessments are accompanied by a telephone conversation between the referrer and the Emergency Duty Service (out of hours) and the Approved Mental Health Professional (AMHP) hub. 2. Risks indicated by the referral will be made explicit in both the referral and the accompanying telephone call by the referrer. 3. The timing of the MHA assessment to be explored with the referrer and any accompanying risk/system issues are to be made explicit so that the management of risk can be agreed/mitigated. I hope that I have provided you with robust assurance that the Trust has taken steps to address the issues of concern in your report, that we are continuing to take action to strengthen the care provided to our patients, and that patient safety is the Trust’s top priority. Yours sincerely, Chief Executive
See every Prevention of Future Deaths report matching Suicide (from 2015), 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.