Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2021-0421, written 14 Dec 2021. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 14 Dec 2021 |
|---|---|
| Reference | 2021-0421 |
| Deceased | Hedley Robinson |
| Coroner | Tom Osborne |
| Coroner area | Milton Keynes |
| Category | Police related deaths · Mental Health related deaths · Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Regulation 28: REPORT TO PREVENT FUTURE DEATHS NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: 1 Chief Executive Officer CNWL 2 Chief Constable 1 CORONER I am Tom OSBORNE, Senior Coroner for the coroner area of Milton Keynes 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 25 April 2019 I commenced an investigation into the death of Hedley Frederick ROBINSON aged 86. The investigation concluded at the end of the inquest on 01 December 2021. The conclusion of the inquest was: Unlawful Killing 4 CIRCUMSTANCES OF THE DEATH The deceased died as a result of multiple stab wounds inflicted at , Newport Pagnell on 24th March 2019. He was transferred to Milton Keynes University Hospital on 5th April 2019 and died on 14th April 2019. 5 CORONER’S CONCERNS During the course of the investigation my inquiries 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: (brief summary of matters of concern) I am concerned that the S.136 Mental Health Act assessment was conducted without full information held by CNWL or discussion with senior police officers and others who had been involved in the care of the deceased’s assailant. There needs to be an urgent review of the operation of S. 136 procedures in Milton Keynes. 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 February 08, 2022. I, the coroner, may extend the period. Regulation 28 – After Inquest Document Template Updated 30/07/2021 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 family of Mr Robinson MK Together Partnership who may find it useful or of interest. 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 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 by the Chief Coroner. 9 Dated: 14/12/2021 Tom OSBORNE Senior Coroner for Milton Keynes Regulation 28 – After Inquest Document Template Updated 30/07/2021
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