Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2021-0203, written 9 Jun 2021. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 9 Jun 2021 |
|---|---|
| Reference | 2021-0203 |
| Deceased | Marc Bennett |
| Coroner | Ian Arrow |
| Coroner area | Plymouth, Torbay and South Devon |
| Category | Community health care · Mental Health related deaths · Suicide (from 2015) |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
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 THIS REPORT IS BEING SENT TO: Devon Partnership Trust Devon County Council CORONER lam lan Arrow, Senior Coroner for Plymouth Torbay and South Devon 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. http://www. legisiation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http:/Avww. legislation.gov.uk/uksi/2013/1629/part/7/made INVESTIGATION and INQUEST Marc David Bennett Opened 27 May 2020 Concluded 9 June 2021 CIRCUMSTANCES OF THE DEATH On the balance of probability the deceased was distressed by his children being taken into foster care. He fashioned a ligature to end his own life at his home address on 24th May 2020 Took own life. 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. — Lessons learned and submitted in the report by Devon Partnership Trust were, there is a need to ensure improved communication by DPT staff with Children’s Services when children are undergoing S47 Child Protection investigations, and/or planning is taking place for care proceedings, to ensure appropriate support to parents open to DPT services with mental health problems OFFICIAL 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. Please review and explain what steps have been taken at an Executive level to ensure improved communication YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 4 August 2021. |, 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 Devon Partnership Trust Devon County Council | 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 mey the coroner, at the time of your response, about the release or the publication of yur prose by the Chief Coroner. Dated 09/06/2021 Signature
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