Prevention of Future Deaths reports · 2020
Regulation 28 report to prevent future deaths, reference 2020-0273, written 6 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 | 6 Nov 2020 |
|---|---|
| Reference | 2020-0273 |
| Deceased | Christopher Murfet |
| Coroner | Paul Cooper |
| Coroner area | Lincolnshire |
| Category | Suicide (from 2015) |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Paul COOPER HM Assistant Coroner County of Lincolnshire REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. United Lincolnshire Hospitals Trust CORONER I am Paul COOPER HM Assistant Coroner for the coroner area of Lincolnshire, 4 Lindum Road, Lincoln, Lincolnshire, LN2 1NN. 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. http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www.legislation.gov.uk/uksi/2013/1629/part/7/made INVESTIGATION and INQUEST On 09/01/2020 I commenced an investigation into the death of Christopher Allan MURFET, aged 31. The investigation concluded at the end of the inquest on 20/10/2020. The conclusion of the inquest was that Christopher Allan MURFET died as a result of Suicide, the medical cause of death being: 1. 2. 3. Hanging (suspension by ligature around the neck) 1a. 1b. 1c. 2. 4. CIRCUMSTANCES OF THE DEATH 1. On 17th October 2019 the deceased presented at Peterborough Hospital after he had self- harmed with Stanley knife 2. On 28th November 2019 the deceased presented at A & E at Pilgrim Hospital, Boston after taking a knife to his throat 3. On 7TH December 2019 the deceased presented again at A & E at the Pilgrim Hospital ,Boston after taking 14 antidepressants. 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 Paul COOPER HM Assistant Coroner County of Lincolnshire 6. 7. Were procedures in place to give consideration to the deceased being sectioned under The Mental Health Act and if not why not as he committed suicide on 29th December 2019. 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. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 16/12/2020. 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 (a) Mr 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. Date: 06/11/2020 Paul COOPER HM Assistant Coroner 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.
INHS: Mr Paul Cooper United Lincolnshire HM Assistant Coroner Hospitals 4 Lindum Road NHS Trust Lincoln LN2 1NN 19 January 2021 Dear Mr Cooper Reference: Regulation 28 Report in relation to Mr Christopher Murfet | am writing in relation to the Regulation 28 report to prevent future deaths that you issued on 6 November 2020 following the inquest held into the death of Mr Murfet on 20 October 2020. In your report, you outlined one area of concern that you wished the Trust to respond to and this is set out below. 1. Were procedures in place to give consideration to the deceased being sectioned under the Mental Health Act and if not why not as he committed suicide on 29 December 2019. HE Consutant and Clinical Lead for A&E has reviewed Mr Murfet’s two previous attendances at Pilgrim Hospital A&E Department on 28 November 2019 and 7 December 2019. On both of these occasions, Christopher was seen and referred to the appropriate psychiatric service from the A&E Department, and subsequently discharged by them. As such we had no reason to use the Mental Health Act to detain him as on both occasions he was willing to engage in the informal assessment process. ‘ | was very saddened to learn of Mr Murfet’s death and please pass on my condolences to his family. ; | hope that this letter provides assurance that the Trust has responded to your concerns and gives a satisfactory response. Yours sincerely Medical Director GMC Trust Headquarters Lincoln County Hospital Lincoln LN2 5QY Telephone ay
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.