Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0327, written 18 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 | 18 Oct 2022 |
|---|---|
| Reference | 2022-0327 |
| Deceased | Max Turbutt |
| Coroner | ME Hessel |
| Coroner area | Inner North London |
| Category | 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: Prevention of Future Deaths report
Max TURBUTT (died 25.04.22)
THIS REPORT IS BEING SENT TO:
1.
Chief Executive
Kent County Council
1
CORONER
I am: Coroner ME Hassell
Senior Coroner
Inner North London
St Pancras Coroner’s Court
Camley Street
London N1C 4PP
2
CORONER’S LEGAL POWERS
I make this report under the Coroners and Justice Act 2009,
paragraph 7, Schedule 5, and
The Coroners (Investigations) Regulations 2013,
regulations 28 and 29.
3
INVESTIGATION and INQUEST
On 3 May 2022, one of my assistant coroners, Sarah Bourke,
commenced an investigation into the death of Max Turbutt, aged 21
years. The investigation concluded at the end of the inquest earlier today.
I made a determination of death by suicide. The medical cause of death
was hanging.
4
CIRCUMSTANCES OF THE DEATH
Max had suffered mental ill health for a number of years. He had been
accommodated under Section 20 of the Children Act and supported by
Kent County Council as a Child in Care, then as a Care Leaver by the 18
Plus Service under Section 23c of the Children Act.
5
CORONER’S CONCERNS
1
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.
Max’s father told me at inquest that in March and April 2022, Max tried
to contact his personal advisor at the 18+ Service at Thistley Hill in Dover
on several occasions over a number of weeks, but found her phone
always to be switched off. There was no redirect and no out of office on
her email.
Max’s father also tried to call her, with the same result. Just over a week
after Max’s death, his family received a letter addressed to him from Kent
Social Services, explaining that his social worker was off sick. A crisis
number was given and Mr Turbutt called it, but it was simply an
answerphone.
This arrangement does not seem adequate for a vulnerable person in
need.
6
ACTION SHOULD BE TAKEN
In my opinion, action should be taken to prevent future deaths and I
believe that you 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 19 December 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 following.
•
• HHJ Thomas Teague QC, the Chief Coroner of England & Wales
, Max’s parents
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.
2
I may also send a copy of your response to any other 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.
9
DATE SIGNED BY SENIOR CORONER
18.10.22 ME Hassell
3
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.
Coroner ME Hassell
Senior Coroner
Inner North London
St Pancras Coroner’s Court
Camley Street
London
N1C 4PP
Sent by email
Kent County Council
Sessions House
County Hall
Maidstone
Kent
ME14 1XQ
Date:
26 January 2023
Dear Coroner Hassell
Prevention of Future Deaths Report – Max Turbutt (died 25.04.22)
I have been asked to write substantively to you given my role as the Council’s
Monitoring Officer.
I would like to start by offering the Council’s apologies for the delay in providing a
response in reply to the correspondence issued under Regulation 28 The Coroners
(Investigation) Regulations 2013 regarding the death of Max Turbutt, who was a young
adult being supported by the Kent County Council 18+ Care Leavers Service.
Having reviewed that letter, you expressed concerns that during March and April 2022
Max tried to contact his Personal Advisor on several occasions over a number of
weeks, but the phone was switched off; that his father also tried, with the same result,
with no redirect or out of office on email. The crisis duty number was tried and went to
a recorded message, asking the caller to leave a message. Max very sadly took his
own life on the 25th of April 2022.
In providing this response, I have liaised with our Corporate Director for Children,
Young People and Education who instructed the Team Manager for the South East
Team of KCC’s 18+ Care Leavers Service to investigate your concerns. As a result of
those investigations, I am able to provide the following information to you.
Max and his Personal Advisor (PA) spoke on 3rd, 7th and 14th of March 2022 and our
contact records show that areas discussed were Max’s wellbeing, his housing options
and support with his claim for Universal Credit. On 16th March, Max was visited in
person by his PA and he said that he was feeling more settled being back in
Folkestone and received advice on his housing options.
During the home visit on 16th March 2022, the PA updated Max’s Pathway Plan, also
discussing this with their line manager during supervision. The following is taken from
Max’s case file:
“During the Home Visit it is recorded that Max seemed more settled with his mental
health by being back in Folkestone. Max has said that he has not heard from
Folkestone council in regard to moving on. It was recommended that he get in contact
with Folkestone council and start looking for accommodation, but he does not wish to
do this. Max has said that he is managing at home and his relationship with his parents
is ok at the moment. Max is still taking anti-depressants and his dose is being slowly
increased. Max is focusing on his mental health and is not looking at getting a job. Max
is still registered with the GP surgery in Blackheath. It has been recommended that he
register with a local GP, but this is not something Max wishes to do at this time. Max's
Dad is collecting prescriptions from London.”
As a follow up to this visit, the PA contacted Max a few days later and supported him
to complete his Universal Credit claim.
On 8th April 2022 there was a telephone call between Max and his PA, where they
advised Max, he should consider changing his GP surgery to Folkestone now he was
back living in Kent.
On 12th April 2022, the PA sent a text to Max, advising they would be going on holiday
soon and reminding him of the duty number to phone if he required support in their
absence. The PA returned to work on 19th April 2022 but was unfortunately taken
unwell which resulted in them going off from work on sick leave.
On the 29th April it became clear that the PA’s sickness was ongoing and would be
longer term and as such, the Team Manager wrote to all the allocated young people
to advise of this and in the letter provided Duty contact details.
Max’s PA went off work officially on sick leave on the 20th April 2022 and there were
only 3 working days after this time, before Max’s tragic death. I am advised that the
Council was aware that Max had fluctuating mental health issues and had sought to
support him intensively the previous year when I am advised Max was very unwell.
Sadly, during their communications with Max, the PA had not seen any indications
during March or early April 2022 to indicate that his mental health was deteriorating.
The PA was advised by Max that he was in regular touch with his GP surgery and had
family locally who were supporting him to collect his medication.
The number provided to Max on 12th April 2022 was the 18+ Care Leavers Service
Duty number. Duty calls are initially answered with the support of our Business
Support Team and a number of Personal Advisors are available on each working day,
during office hours, to respond to phone calls and provide emergency support to our
2,000 Kent young adults who are care leavers. At times of exceptional demand, if the
call cannot be answered, it goes to an answer phone, and our Duty workers will ring
people back the same day. If outside of office hours, Kent County Council also has an
Out of Hours Service to support with emergencies that cannot wait until the next
working day. We have no record of a message being left by Max or his father but are
happy to further investigate any additional details.
In direct response to the concerns you raised, when a tragic event happens, our
service reviews any learning and on investigation of the concerns raised, whilst there
was only a very short period of time between the Personal Advisor going off unwell
and Max’s death, the service has made the following changes:
• Young adults will be advised immediately if their allocated Personal Advisor is
off longer-term sick and provided with the name of the Team Manager,
alongside the Duty contact number.
• The Team Manager will ask the relevant staff member to add a voice message
to their mobile phone advising of who to contact in their absence.
• The Team Manager will ensure an Out of Office reply is added to the staff
members email account if they are to be off on a longer-term basis.
Kent County Council send our condolences to Max’s family for their sad loss. I am also
advised that Max’s suicide has been very upsetting to the service, and particularly his
Personal Advisor, who from the regular communication they had with Max, had built a
good relationship with him.
We hope this information answers your concerns, but please do not hesitate to contact
me if I can be of any further assistance.
Yours sincerely
Monitoring Officer
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