Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0192, written 21 Jun 2022. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 21 Jun 2022 |
|---|---|
| Reference | 2022-0192 |
| Deceased | Kate Hyatt |
| Coroner | Crispin Oliver |
| Coroner area | West Yorkshire Western |
| Category | Mental Health related deaths · Suicide (from 2015) |
| 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 NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: 1 1 CORONER , Principal, Hands of Light Academy I am CRISPIN OLIVER, Assistant Coroner for the coroner area of West Yorkshire (Western) Area. 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. INVESTIGATION and INQUEST 3 On 12 November 2021 I commenced an investigation into the death of Kate Angharad HYATT aged 32. The investigation concluded at the end of the inquest on 09 June 2022. The conclusion of the inquest was: Suicide 4 CIRCUMSTANCES OF THE DEATH Pronounced dead at 03.31 on 31 October 2021 at Widdop Road, Hebden Bridge. Died of toxity and the conclusion of the inquest was suicide. 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: The evidence at the inquest was that Kate had become depressed for the last 12-18 months of her life. Her family described her as displaying signs of psychosis. Obviously, the causes of the decline in her mental health toward the end of her life were likely complex and multiple. The evidence was however, that she had become particularly disturbed over the 3-4 months immediately prior to her death. Specifically, these symptoms had worsened significantly subsequent to her attendance at a Hands of Light Academy course in Worcestershire; which took place on 18th-22nd June 2021. , . My concern is that hallucinogenic substances are being dispensed by the Hands of Light Academy to attendees on its courses, potentially and/or actually mentally unwell people, without proper, or any, consideration of the impact that they may have on them. In particular is the effect of hallucinogens on psychosis sufferers. 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 Regulation 28 – After Inquest Document Template Updated 30/07/2021 You are under a duty to respond to this report within 56 days of the date of this report, namely by August 16, 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 I have also sent it to 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: 21/06/2022 Crispin OLIVER HM Assistant Coroner for West Yorkshire Western Coroner Area Regulation 28 – After Inquest Document Template Updated 30/07/2021
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.
Dear Sir, Thank you for your report regarding Kate Angharad Hyatt. I have responded below as requested but should like to point out that the response time given has been extremely short considering the nature of this matter. Also, that the scarcity of detail or context in the initial correspondence (09/08/2022) made it difficult to discern whether the email was genuine or a hoax. However, I am responding as thoroughly as possible in order to meet your deadline. An initial review of our records does not show any student by the above name as having attended one of our courses. On the said dates you mention, there were no Hands of Light Academy courses running. Regarding dispense the above-named substance to our students. , Hands of Light Academy is a teaching establishment and we do not We undertake screening of all our students prior to them undertaking any course with us. If any student divulged such a history, we would not accept them onto a course as the nature of the work is challenging and can bring up emotional content. In regards to what actions will be taken by Hands of Light Academy, we will: 1. Ensure the continued, thorough screening of all prospective students. 2. Educate our staff about the use of hallucinogens and their potential dangers. 3. Maintain vigilance regarding students’ behaviour and habits whilst under our care and supervision Inform the relevant authorities if we have reason to suspect a student or 4. member of staff is presenting a potential danger to themselves or another Co-Founder & Principal Hands of Light Academy (HOLA) Healing & Energy Works for Empowerment & Transformation
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