Prevention of Future Deaths reports · 2020
Regulation 28 report to prevent future deaths, reference 2021-0010, written 18 Dec 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 Dec 2020 |
|---|---|
| Reference | 2021-0010 |
| Deceased | Jennifer Spencer |
| Coroner | James Healy-Pratt |
| Coroner area | East Sussex |
| Category | Mental Health related deaths · Alcohol, drug and medication 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 (1) NOTE: This from is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: 1 CORONER , CEO NHS England I am James Healy-Pratt, Assistant Coroner for the area of East Sussex. 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 19/11/2019 16:15 I commenced an investigation into the death of Jennifer Sarah Myfanwy SPENCER aged 29. The investigation concluded at the end of the inquest on 10 December 2020. The conclusion of the inquest was: I a Multiple injuries I b I c II 4 CIRCUMSTANCES OF THE DEATH This young lady's mental health deteriorated following ingestion of Shamanic Hallucinogenic Drugs and Kundalini Yoga; resulting in her deliberately falling from Beachy Head on 16th November 2019; intending to end her life; whilst the balance of her mind was disturbed. 5 CORONER’S CONCERNS There is a lack of awareness amongst Mental Health Professionals about “Shamanic” hallucinogenic drugs and their propensity to cause or exacerbate psychosis. This results in sub-optimal assessment, treatment and care. Ayahuasca, DMT and similar “Shamanic” hallucinogens are becoming more commonplace in the UK. Greater learning about them is required by Mental Health Professionals. Ref – Therapeutic Advances in Psychopharmacology 2017, Vol. 7(4) 141-157, dos Santos, Hallak, Mouso. 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 09 February 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 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 James HEALY-PRATT Assistant Coroner for East Sussex Dated: 18 December 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.
Mr Alan Craze, HM Senior Coroner East
Sussex)
Coroner’s Office (East Sussex)
Unit 56
Innovation Centre
Highfield Drive
St Leonards on Sea
East Sussex
TN38 9UH
National Medical Director
Skipton House
80 London Road
SE1 6LH
18th June 2021
Dear Mr Craze,
Re: Regulation 28 Report to Prevent Future Deaths – Jennifer Sarah Myfanwy
Spencer (16 November 2019)
Thank you for your Regulation 28 Report dated 13 January 2021 concerning the
death of Jennifer Sarah Myfanwy Spencer on 16 November 2020. Firstly, I would
like to express my deep condolences to Jennifer’s family. My apologies for the
delay in responding.
The regulation 28 report concludes Jennifer’s death was a result of multiple injuries
and death by suicide.
Following the inquest, you raised concerns in your Regulation 28 Report to NHS
England regarding a lack of awareness amongst Mental Health professionals about
‘Shamanic’ hallucinogenic drugs and their propensity to cause or exacerbate
psychosis, resulting in sub-optimal treatment and care. In this response I will set out
the steps we are taking in NHS England/ Improvement to address the issues
outlined in your report.
Reducing suicide and preventing self-harm is a key priority for NHS England/
Improvement. We are working closely with partners, including Public Health
England and the Department of Health and Social Care to support local areas to
deliver multi-agency suicide prevention plans. As part of the £2.3billion settlement
for mental health in the Long Term Plan, we are providing targeted and ring-fenced
funding to all Sustainability and Transformation Partnerships (STPs) so they can
deliver their multi-agency plans. This includes suicide prevention activities,
initiatives to prevent self-harm and putting in place postvention bereavement
support. By 2023/24, this will total £57M additional investment in suicide prevention
and bereavement.
To support these STPs, there is a bespoke national suicide reduction support
NHS England and NHS Improvement
package with the National Confidential Inquiry into Suicide and Safety in Mental
Health (NCISH) and National Collaborating Centre for Mental Health (NCCMH)
working together to support STPs in their quality improvement plans, as part of the
national suicide prevention programme.
Key components of this support programme include supporting services with safety
planning, using resources such as The National Confidential Inquiry into Suicide
and Safety in Mental Health (NCISH) ‘Safer services: A toolkit for specialist mental
health services and primary care’, which includes guidance for mental health
services to work jointly with local substance misuse services and having specific
training in place for staff on substance misuse assessment. I know that the South
East region suicide prevention lead is working to raise awareness and escalate
concerns regarding ‘shamanic hallucinogenic drugs’ via relevant forums to increase
awareness and understanding of this risk factor. Furthermore, based on the insights
provided in this report, the NHSE/I National team will share any outputs and
learning generated by the South East regional team with all other suicide prevention
regional leads and teams nationally.
In addition to this, as part of the NHS Long Term Plan’s commitment to transform
community mental health services, we are investing £181M in psychological
therapies for severe mental illness (SMI). This includes the roll-out of
‘understanding psychosis and bipolar disorder’ training, which will be rolled out
across staff working in community mental health teams over the next three years.
The aim of this training is to ensure those working with people presenting with
psychosis recognise the diverse bio-psychosocial factors (including substance use)
that can impact upon a person's mental health.
Your concerns around the lack of awareness of Shamanic hallucinogens are noted.
It would be relevant that colleagues at Public Health England are better placed to
consider this in their work on “Misuse of illicit drugs and medicines guidance”. I
have shared your report and our response with my colleague Yvonne Doyle.
Thank you for bringing these important patient safety issues to my attention and
please do not hesitate to contact me should you need any further information.
Yours sincerely,
National Medical Director
NHS England and NHS Improvement
NHS England and NHS Improvement
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