Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0102, written 5 Apr 2022. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 5 Apr 2022 |
|---|---|
| Reference | 2022-0102 |
| Deceased | Ryan Merna |
| Coroner | Richard Middleton |
| Coroner area | Dorset |
| Category | Other related deaths · Hospital Death (Clinical Procedures and medical management) related deaths · Mental Health related deaths · Community health care |
| Organisation named | Dorset Healthcare University NHS Foundation Trust |
| 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 (1)
NOTE: This form is to be used after an inquest
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
1. The Chief Executive, Dorset Healthcare University NHS
Foundation Trust
1
CORONER
I am Richard T Middleton, Assistant Coroner, for the Coroner Area of Dorset
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 the 17th August 2016, an investigation was commenced into the death of
Ryan Albert Frederick Merna, born on the 19th November 1986.
The investigation concluded at the end of the Inquest on the 29th March 2022.
The Medical Cause of Death was:
la Stab wounds to the chest and abdomen
The conclusion of the Inquest recorded that Ryan Albert Frederick Merna was
unlawfully killed in circumstances where the perpetrator was under the care of
mental health services and there was a missed opportunity to reassess the risk
the perpetrator posed to others in light of new information disclosed 5 days
before Mr Merna's death.
4
CIRCUMSTANCES OF THE DEATH
Mr Merna died from injuries sustained in a knife attack at his home
address on 14/8/16. On the 8th August 2017 the perpetrator of the
assault was convicted at Winchester Crown Court of the offence of
Manslaughter on the grounds of Diminished Responsibility. The
perpetrator was being treated as an outpatient under the care of the
Dorset Forensic Team from May 2016 until Mr Merna's death. His
treating psychiatrist saw him in person on 3 occasions on 26/5/16,
29/6/16 and 10/8/16. He was seen regularly by outpatient support in
the form of a Care Coordinator and a Forensic Social Worker.
1
The Forensic Social Worker was trying to find suitable accommodation
as the perpetrator was of no fixed abode. On 9/8/16 the Forensic
Social Worker accompanied the perpetrator to an assessment meeting
at a possible housing provider. During the course of that meeting the
perpetrator disclosed that he was in possession of a knife, that he was
sleeping rough and he needed the knife for his own protection. On
10/8/16 there was a Care Programme Meeting at which the
Psychiatrist, Care Coordinator, Social Worker and perpetrator were all
present. One of the purposes of the meeting was for the team to raise
any significant developments so that a risk assessment could be made.
The disclosures made at the housing assessment on 9/8/16 were
neither documented at the time nor raised during the CPA meeting on
10/8/16.
5
CORONER'S CONCERNS
The MATTERS OF CONCERN are as follows:
1. During the inquest evidence was heard that:
i.
ii.
iii.
iv.
The members of the Dorset Forensic Team did not probe as to
where the perpetrator was sleeping.
The disclosure made by
in
possession of a knife was not probed further by the Social
Worker.
the perpetrator
that he was
in
The disclosure made by
possession of a knife was not recorded contemporaneously in the
perpetrator's records.
the perpetrator
that he was
in
The disclosure made by
possession of a knife was not raised during a Care Programme
Meeting held the day following the disclosure.
the perpetrator that he was
2
2.
I have concerns with regard to the following: The Trust Clinical Risk
Policy should make reference to the fact that
i.
The Trust should use its best endeavours to identify where a
service user is living by reference to information to be sourced
from the individual and from that which may be in the public
domain.
ii. Where there is disclosure that a service user is in possession of
an offensive weapon this must be documented; there must be a
documented discussion as to the response; the information must
be passed to the police; any action taken by the Trust and/or the
police to be documented.
6
ACTION SHOULD BE TAKEN
In my opinion urgent 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, 31st May 2022. 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:
(1)
(2)
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.
9
Dated
S/ <f('l-1-
Signed/-~ " '
Richard T Middleton ~
3
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