Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0313, written 12 Oct 2022. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 12 Oct 2022 |
|---|---|
| Reference | 2022-0313 |
| Deceased | Emma Simkin |
| Coroner | Paul Cooper |
| Coroner area | Lincolnshire |
| Category | Railway related deaths |
| 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 Vine Street Sugery, Grantham 2 LPFT Legal Services 3 Legal Services Lincolnshire 1 CORONER I am Paul COOPER, HM Assistant Coroner for the coroner area of Lincolnshire 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 01 March 2021 I commenced an investigation into the death of Emma Jane SIMKIN aged 24. The investigation concluded at the end of the inquest on 11 October 2022. The conclusion of the inquest was that: The deceased died on 20th February 2021 at Railway Lineside, Spitalgate Hill, Grantham by standing in front of a freight train and receiving non-survivable injuries. 4 CIRCUMSTANCES OF THE DEATH Incident was initially referred to the Coroner by way of EMAS Diagnosis of Death form then later by BTP Police. This matter relates to the death of a 24 old female found on the railway line near Grantham having been struck by a freight train. Deceased was single having never married nor had children. She is survived by her parents and sister from whom she had been estranged for 2 years. Deceased's birth name is Emma Jane SIMKIN but at some point over the last 2 years changed it to Emilie Zukiard AFFIN but all her medical records are in her birth name. She lived in a multi occupancy house at the address stated. Medical background/history: long term mental health issues and was under the Mental Health Team with Paranoia and Bipolar Disorder. Medications: Lithium. Routine bloods taken on 11/12/20. Last contact with GP by telephone 14/12/20. No significant medical issues known. Working hypothesis at this moment in time is that in the early hours of 20/02/21 deceased had been in the Aldi car park, which is directly above the point of impact. and was struck by a freight train. Reported by train driver who contacted his control stating that he had struck something. There is no CCTV at the point of access to the railway lines. Substantial amount of property recovered from scene including driving licence and notes. All currently being reviewed. Driving Licence, found on railway tracks and near perceived point of impact, in the name of Emilie Zukiaro AFFIN b. 16/03/1996. Additionally a bag with matching identification located in nearby Aldi car park. Some notes relate to intimating suicide and mental health issues have been recovered and which are thought to relate to the deceased. Death confirmed at scene by Paramedics at 0342 hrs. BTP officers attended scene. Body Regulation 28 – After Inquest Document Template Updated 30/07/2021 . Cause of death; 1a Multiple , have been traced and informed. badly disrupted. ID confirmed by photo ID found at scene and by fingerprints. NOK (parents) has also spoken to them at length. BTP continuing investigation. Standard PM required to establish and confirm cause of death. Samples to be taken for toxicology to check for alcohol and drugs/medications. DS 01/03/21 - PM carried out at QMC on 26/02/21 by Traumatic Injuries subject to toxicology. NOK - father and BTP updated. Body released. Please can an Inquest be opened and adjourned in relation to this matter. Interims to be sent to the deceased's father; tab Burial Order to be sent to Sun Rising Funerals Warwickshire. Please write to the following to request reports and statements: GP re deceased's medical background and history, LPFT Mental Health Services re engagement with their services Addaction - We Area With You to establish if deceased had any dealings with them. All other reports and statements are in hand. DS 06/04/21 - Toxicology and PM reports received. NOK updated. Copies of reports sent to BTP ( Toxicology - A low level of ethanol was detected which may have resulted from post mortem changes. No other significant toxicological findings. The liver tissue sample was unsuitable for lithium analysis. PM result: 1a - Multiple Traumatic Injuries 1b - Collision with train. DS - address on wpc contact 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) Families are repeatedly advising their perception is that loved ones are successfully "masking" their mental illnesses in front of professionals who are perceived to accept at face value what they are told rather than looking at other primary evidence more often than not from the families themselves. which in turn leads the families to believe they are being ignored and lives lost. Can you reassure me that policies are in place that focus upon how to identify "masking" and adequate training to the appropriate professionals is up to date and consider if policies are in need of review. 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 December 06, 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 Regulation 28 – After Inquest Document Template Updated 30/07/2021 Peter Richard SIMKIN 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: 12/10/2022 Paul COOPER HM Assistant Coroner for Lincolnshire 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 Mr Cooper 5.12.22 REGULATION 28 REPORT – EMMA JANE SIMKIN Thank you for your letter dated 10th October 2022 enclosing your Regulation 28 Report following the inquest investigating the death of the late Emma Jane SIMKIN. As required under Section 7 of your report, we have now considered your points and respond accordingly. Your concerns Your concerns listed in the report are: “Families are repeatedly advising their perception is that loved ones are successfully "masking" their mental illnesses in front of professionals who are perceived to accept at face value what they are told rather than looking at other primary evidence more often than not from the families themselves which in turn leads the families to believe they are being ignored and lives lost. Can you reassure me that policies are in place that focus upon how to identify "masking" and adequate training to the appropriate professionals is up to date and consider if policies are in need of review.” The death of Emma Simkin The deceased sadly died on 20th February 2021 at Railway Lineside, Spitalgate Hill, Grantham by standing in front of a freight train and receiving non-survivable injuries. Involvement of Lincolnshire County Council Lincolnshire County Council’s only involvement in this case was through its provision of Approved Mental Health Professionals. (AMHP). The Council did not attend the inquest, was not an interested party but did provide two statements from two AMHPS who were not required to give evidence. The AMHPs did not see the deceased at any point during their involvement. The issue therefore of “Masking” (hiding or suppressing symptoms of a mental health condition) was not relevant to the AMHP’s on the specific facts of this particular inquest. We further understand there is a no criticism of the local authority in this case. We do understand however that a feature of some inquests (we have not been provided with specifics) is that families are repeatedly advising coroners that loved ones are successfully masking their mental illnesses in front of professionals who are perceived to accept at value what they are told. Whilst it had no application in this case as the AMHPS did not see the deceased we have been asked to provide a generic response to your concerns. Masking The Council does not have a separate masking policy. However the AMHP is required to act in accordance with the Mental Health Act 1983 and in particular in accordance with the Mental Health Act 1983: Code of Practice. This Code of Practice is statutory guidance on how the AMHPs should carry out their functions under the Act. Furthermore, the council is required to test the competencies of the AMHPS it is responsible for approving in accordance with the Mental Health (Approved Mental Health Professionals (Approval) (England) Regulations 2008 as detailed in schedule 2. It is a feature of AMHP assessments that the AMHP does not ever rely solely on the presentation of the individual concerned in reaching a conclusion as to whether the individual requires an admission to hospital. The assessment process All requests for a Mental Health Act assessment are triaged to determine whether assessment is necessary and proportionate. Triage under the Mental Health Act incorporates a holistic assessment of the person’s needs. Triage includes a comprehensive review of all the available information from looking at the Mental Health Trust and local authority records but also through a detailed level of communication with the referrer and/or other professionals involved in any care and treatment. Views from the nearest relative and family members with specific knowledge regarding the person’s risks and mental state are also sought and considered. AMHPs must demonstrate that they are competent in balancing and managing the competing requirements of confidentiality and effective information sharing to the benefit of the patient and other persons concerned in the patients care (2008 Regulations para 4(k)) Where a decision is made to assess Assessment under the Mental Health Act comprises of an AMHP assessing the person with two doctors, one of whom must be approved under section 12 of the Mental Health Act, and wherever possible, with prior acquaintance of the person. In many cases the AMHP is also accompanied by a member of the person’s care team as it is acknowledged that the AMHP is only involved for a very short period in the persons overall involvement with services. Paragraph 14.9 of the Code of Practice outlines factors that the AMHP should consider when assessing the health or safety of a potential patient:- • The evidence suggesting that patients are at risk of suicide, self harm, self neglect, jeopardising their own health and safety accidentally, recklessly or unintentionally or that their mental disorder is otherwise putting their health and safety at risk • Any evidence suggesting that the patient’s mental health will deteriorate if they do not receive treatment including the views of the patient or carers, relatives, close friends (especially those living with the patient about the likely course of the disorder) • The patient’s own skills and experience in managing their condition • The patient's capacity to consent to or refuse admission and treatment • Whether the patient objects to treatment for mental disorder or is likely to • The reliability of such evidence, including what is known of the history of the patient's mental disorder and the possibility of their mental health improving • Potential benefits of treatment weighed against any adverse effects of being detained • Whether other methods of managing the risk are available. The Code ensures that the assessment is therefore a holistic one that incorporates all the information available to make a decision in the best interests of the patient. Concerning the masking of mental disorder it is clear that care must be taken to weigh the persons own account against the available information from other sources and this can therefore lead to an action that the person may be compliant with treatment but nevertheless requires compulsory detention based on the evidence at hand. Training and Competencies In order to fulfil the functions of the Mental Health Act, a professional of the proscribed class must undertake a master’s level post graduate course in the role. This training focuses on the legal parameters of the role but also on the overriding principle that the AMHP is the decision maker in the Mental Health Act and should have a robust legal knowledge of such. However, the training also incorporates the ethical and moral aspects of the role including contact with the nearest relative and the least restrictive principles. All AMHPs are legally required to undertake 18 hours of mandatory training every year that comprises of a legal update and two context specific training sessions. AMHP’s are approved by the local authority every 5 years and must demonstrate competency against the Key competencies set out in the MH (AMHP) (Approval) (England) Regulations 2008 by undertaking a detailed appraisal that incorporates assessment skills and reflective practice. This is in addition to an annual review that confirms that the mandatory training has been completed and must show evidence of compliance with the core AMHP competencies of Social Work England. In addition to the above all AMHP’s have access to comprehensive support for their development including regular 1-1’s, meetings and the AMHP forum that runs three times yearly and includes legal updates as well as discussions with providers. AMHPs must demonstrate competence in the application of knowledge of mental disorders, including the implications for patients, their relatives and their carers (2008 Regulations, para 3(c)). AMHP training highlights that those self-reporting mental health conditions may be motivated by factors such as a desire not to receive any further mental health support. For example, in 2021 AMHPs undertaking assessments on behalf of Lincolnshire County Council completed mandatory suicide and risk training which outlined specifically that whilst the person’s views were an important part of the assessment process, the evidence for risk in suicide should be based on a review of all the factors of the case, including the views of the family. AMHPs must demonstrate that they are competent in recognizing, assessing and managing risk effectively in the context of their role (2008 Regulations, para 4(f)), AMHPs gather information and views from a wide range of sources, including family members, responsible clinicians, care teams and the two Doctors attending the assessment, and then weigh and use this information to make an informed decision. Policy reviews and intended action Whilst there is no specific policy about masking due to the comprehensive nature of the code, the ongoing mandatory training and the robust measures in place to ensure that AMHPs remain competent to practice, it is the Council’s intention to review its policies with a view to adding in and strengthening its general policies to incorporate references where appropriate to masking. The Council also intends to put on the agenda of the next AMHP Forum the topic of "Masking" so that it can appraise all the AMHPS of the coroner's general concerns about masking and to ensure that discussion and good practice issues can be explored with the AMHP group as a whole on that day. The Next AMHP forum is due to take place on Tuesday 10th January 2023 between 9.30 and 1.30pm. Recognising the tragic impact of suicide on families, friends, and communities, in 2020, Lincolnshire introduced its suicide prevention strategy 2020-2023 which is supported by 26 different organisations across Lincolnshire. Its vision is to make Lincolnshire a place where suicide is not considered as an option and people continue to have hope. The Director of Public Health (DPH) is formally responsible for the development of a local Suicide Prevention Strategy and Action Plan through co-production with partners across Lincolnshire. The governance arrangements for the development and implementation of this strategy and action plan, including monitoring performance, lays with Lincolnshire Safeguarding Adults Board (LSAB) and Lincolnshire Safeguarding Children Partnership (LSCP), with assurance provided to the Lincolnshire Health and Well-being Board. We trust the above addresses your concerns.
See every Prevention of Future Deaths report matching Railway related deaths, 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.