Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2021-0261, written 30 Jul 2021. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 30 Jul 2021 |
|---|---|
| Reference | 2021-0261 |
| Deceased | Amanda Dunn |
| Coroner | Andrew Haigh |
| Coroner area | Staffordshire (South) |
| Category | Police related deaths · Suicide (from 2015) · Mental Health related deaths · Alcohol, drug and medication related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Her Majesty's Coroner Staffordshire (South) Coroner's Jurisdiction Date: 30 July 2021 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Staffordshire Police , Temporary Chief Constable, CORONER: I am Mr Andrew A Haigh Senior Coroner for Staffordshire South 1. 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.leqislation.qov.uk/ukpqa/2009/25/schedule/5/paraqraph/7 http://www. legislation .qov. uk/u ksi/2013/1629/part/7 /made 2. INVESTIGATION and INQUEST On 23 March 2021 I commenced an investigation into the death of Amanda DUNN. The investigation concluded at the end of the inquest on 29 July 2021. The conclusion of the inquest was 'suicide while suffering anxiety and depression' with the cause of Ms Dunn's death being 'mixed drug toxicity'. 3. CIRCUMSTANCES OF THE DEATH Amanda Dunn died at home on 21 March 2021 from a massive self-administered overdose of prescribed medication. She had a history of mental illness and also had caring responsibilities but a major reason for her fatal actions was an ongoing problem with neighbours. 4. CORONER'S CONCERN During the course of the inquest the evidence revealed a matter 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. 5. The MATTER OF CONCERN is as follows: Family members told me that for a period of about two years prior to her death Amanda had received a lot of aggravation from a set of neighbours. Police were contacted several times but took no action. The evidence I heard clearly seemed to amount to harassment. Prior to the inquest I was not aware of the full extent of the concerns and had not requested evidence from the police on this (PC about the circumstances of the death itself). I realise therefore that I have only heard one side of the story but there is a real concern that police are seeking to brush such incidents under the carpet and not taking them sufficiently seriously. Clearly, I do not gave evidence 1 Staffordshire Place, Stafford, ST16 2LP want another death reported to me of a similar nature. 6. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you 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 24 September. 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 Amanda's family. 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. 30 July 2021 Andrew A Haigh HM Senior Coroner for Staffordshire South 1 Staffordshire Place, Stafford, ST16 2LP
2 responses 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.
The Office of T/Deputy Chief Constable Date: 30 September 2021 Mr Andrew A Haigh HM Coroner Staffordshire South 1 Staffordshire Place Stafford ST16 2LP Dear Mr. Haigh With reference to your Regulation 28 notice of 30 July 2021 and my response dated 23 September 2021 with regard to the death of Amanda Dunn, I have further information that you need to be aware of. In my response dated 23 September 2021, I explained that the circumstances of the case had been assessed and considered by Staffordshire Police’s Professional Standards Department, who concluded that no misconduct had been identified. I wish to update you that the case met the criteria for a mandatory referral to the Independent Office for Police Conduct (IOPC). Following our referral, the IOPC commenced an independent investigation and will update us in due course. Amanda’s family are aware of this and have been provided with the relevant contact details. Please accept my sincere apologies for not informing you of this at the time and I will of course update you when we receive their findings. Yours sincerely, T/DCC Staffordshire Police
The Office of Temporary Deputy Chief Constable
Date: 23 September 2021
Mr Andrew A Haigh
HM Coroner
Staffordshire South
1 Staffordshire Place
STAFFORD
ST16 2LP
Dear Mr. Haigh
I write in reference to your Regulation 28 notice of 30 July 2021 with regard to the death of
Amanda Dunn.
Firstly, I want to express my deepest condolences to the family of Mrs. Dunn and can report that
Staffordshire Police have reviewed the full circumstances of her death and those leading up to it,
including events back to January 2019. Having conducted a review of Staffordshire Police contact
with Mrs. Dunn it has been established that there were six occasions between 14 January 2019
and 18 December 2020 when Mrs. Dunn was mentioned, namely 14 January 2019, 12 April 2019,
a second occasion on 12 April 2019, 13 November 2019, 6 August 2020 and 18 December 2020.
Of those six occasions Mrs. Dunn contacted Staffordshire Police twice, namely on 13 November
2019 and 6 August 2020, when she reported anti-social behaviour by her neighbour including on
13 November mention of being pushed by her neighbour. Aside from this on 12 Apr 2019 police
officers spoke with Mrs. Dunn who described difficult relations with her neighbours. The other
dates when Mrs. Dunn was mentioned were when her neighbours contacted Staffordshire Police
or a report was made to “Crimestoppers” and reference was made to her. The final date that
Staffordshire Police had contact with Mrs. Dunn was 21 Mar 2021 when they attended her
property and she was found to be deceased.
The examination of this chronology of events has identified some areas where the police could
and should have performed better. This includes the important role of the police to make and
record referrals to partner agencies, including mental health services to provide a better
understanding of the entire circumstances and their impact.
In addition, the police did not respond effectively to the allegation of a criminal offence (the
pushing incident). We have found no material where the police have confirmed, recorded or
explored this allegation. This learning has been promptly shared with colleagues who are
responsible for neighbourhood policing, the thematic business lead for anti-social behaviour as
well as the specific officers responsible for the area in which Mrs. Dunn lived.
More broadly, the Force is reviewing whether there are any similar repeat cases of anti-social
behaviour which have been reported to Staffordshire Police that involve vulnerable people. The
aim of this work is to identify any cases that have been reported to Staffordshire Police which
need additional work, in response to these findings. The second aim is to examine our systems
and processes to ensure we provide a consistently good level of service to those people who
report matters of anti-social behaviour.
A criminal investigation has commenced and is being carried out by the Force’s Criminal
Investigation Department. This investigation will look at any potential criminal offences
committed against Mrs Dunn and her family. Mrs Dunn’s family have been listened to and their
concerns have been comprehensively recorded. Due to the live and on-going status of this I am
unable to expand further, however, at the conclusion I can provide an update to you.
The circumstances of this case have also been assessed and considered by the Professional
Standards Department, who have concluded that no misconduct has been identified.
Finally, the police are keen to understand if further information was known by partner agencies
and if broader partnership learning can be achieved through wider understanding of this case.
Consequently we have written to colleagues within the Staffordshire and Stoke on Trent Adult
Safeguarding Partnership Board.
Once all of the information is available we will assess it to identify any learning opportunities.
This work will take a little longer to complete as it involves the combined effort of partner
agencies, but again, once completed it can be shared with you.
I want to reassure you that we take this matter very seriously and are committed to ensuring
that the learning from this case is captured, understood and disseminated in a way that prevents
future re-occurrences.
Yours sincerely,
T/DCC
Staffordshire Police
CC D/Supt
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