Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0211, written 14 Jul 2022. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 14 Jul 2022 |
|---|---|
| Reference | 2022-0211 |
| Deceased | Kieran Crimmins |
| Coroner | Paul Bennett |
| Coroner area | Carmarthenshire and Pembrokeshire |
| Category | Suicide (from 2015) · Mental Health related deaths · Wales prevention of future deaths reports (2019 onwards) |
| 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.
Paul Bennett
Uwch Grwner dros dro ar gyfer Sir Benfro a Sir Gar
Acting Senior Coroner for Pembrokeshire and Carmarthenshire
Our Ref: 116559
Date: 12 July 2022
All correspondence should be addressed to
the Coroner and Emails sent to:-
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
1
2
THIS REPORT IS BEING SENT TO: Hywel Dda University Health Board
CORONER
I am Paul Jonathan Bennett the Acting Senior Coroner for Pembrokeshire and
Carmarthenshire
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.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7
http://www.legislation.gov.uk/uksi/2013/1629/part/7/made
Pembrokeshire County Council / Cyngor Sir Benfro
NW0C
County Hall / Neuadd y Sir
Haverfordwest / Hwlffordd
SA61 1TP
INVESTIGATION and INQUEST
On 29 March 2019 I commenced an investigation into the death of Kieran Joseph
Kevan CRIMMINS. The investigation concluded at the end of the inquest . The
conclusion of the inquest was Suicide.
3 1a Hanging
1b
1c
II
CIRCUMSTANCES OF THE DEATH
I found that Kieran Joseph Kevan Crimmins took his own life and intended to do so in
circumstances where ongoing psychiatric monitoring and support would have been
4 appropriate. A decision was taken not to refer to the Community Mental Health Team for
ongoing monitoring of his mental health and care co-ordination following his discharge
from the Crisis and Home Treatment Team on the 5th March 2019 due to the fact that he
was receiving support from the Dyfed Drug and Alcohol Service and the Independent
Psychological Therapy Service.
Pembrokeshire County Council / Cyngor Sir Benfro
NW0C
County Hall / Neuadd y Sir
Haverfordwest / Hwlffordd
SA61 1TP
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. –
(1) I was told that the Crisis Recovery and Home Treatment Team ("CRHT") use the
Care Partner records, a whiteboard and a manual diary to enter the various information
and action points and that it is at the Multidisciplinary Team meetings that the actions or
steps are discussed and progressed. They are either crossed out, if completed, or
moved to the next date until they have been actioned. It was highlighted that in this
particular case two actions were not completed either prior to Kieran’s discharge from
the CRHT or shortly thereafter. In one of these, the entry had been crossed out, giving
the impression that the matter had, in fact been dealt with when it had not. This indicated
that there was an issue as to the monitoring and execution of such actions or steps.
This anomaly whereby a significant step may have been overlooked remains a concern.
(2) The evidence I heard from one witness described how she was asked to contact
Kieran by telephone and to advise him of the fact that a Multi-agency Referral Form
(“MARF”) was to be submitted. I considered this was an inappropriate means of
communicating a significant procedure and which could potentially bear on his (or any
other vulnerable person's) state of mind.
What was unclear is how the provision of this information and step to be taken will be
approached in future.
(3) I expressed concern that someone having been discharged from the CRHT, there
appeared to be no route back into the Mental Health Service short of a re-referral to the
CRHT itself via A & E for someone who remains vulnerable by reason of their mental
state and who is receiving therapy as part of the discharge plan. This is in the context of
someone who was receiving support from the Integrated Psychology Therapy Service
(“IPTS”) and the Dyfed Drug and Alcohol Service (“DDAS”), both of whom were engaged
in providing appropriate therapies.
My concern is that there appears to be an issue in relation to lines of communication and
information sharing between Primary Mental Health Services and Tier 2 providers of
therapy.
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe you Hywel
Dda University Health Board have the power to take such action.
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report,
5
6
7
Pembrokeshire County Council / Cyngor Sir Benfro
NW0C
County Hall / Neuadd y Sir
Haverfordwest / Hwlffordd
SA61 1TP
namely by 9th September 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.
COPIES and PUBLICATION
I have sent a copy of my report to the Chief Coroner and to the following Interested
Persons:
; Dyfed Drug & Alcohol Service.
I am also under a duty to send the Chief Coroner a copy of your response.
8
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.
14 July 2022
9
Signature
Paul Jonathan Bennett
Acting Senior Coroner
Pembrokeshire County Council / Cyngor Sir Benfro
NW0C
County Hall / Neuadd y Sir
Haverfordwest / Hwlffordd
SA61 1TP
See every Prevention of Future Deaths report matching Suicide (from 2015), and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.