Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2022-0402, written 11 Aug 2021. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 11 Aug 2021 |
|---|---|
| Reference | 2022-0402 |
| Deceased | Hadley Savory |
| Coroner | Ian Brownhill |
| Coroner area | North East Kent |
| Category | Alcohol, drug and medication related deaths |
| Organisation named | East Kent Hospitals 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.
North East Kent Coroners Cantium House 2nd Floor Maidstone Kent ME14 1XD REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. The Chief Executive of The Forward Trust 2. The Chief Executive of Kent and Medway NHS and Social Care Partnership Trust 3. The Chief Executive of the East Kent Hospitals University NHS Foundation Trust 1 CORONER I am Ian Brownhill, assistant coroner, for the coroner area of North East Kent 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 Hadley John Savory was found dead at his home address in Margate on 13 December 2019. An investigation into his death was commenced. The investigation concluded at the end of the inquest on 11 August 2021. My conclusion was that his death was drug related, in addition, a short narrative conclusion was given as explained further under section 4 below. 4 CIRCUMSTANCES OF THE DEATH Hadley John Savory was discharged from Queen Elizabeth The Queen Mother Hospital on 25 September 2019. A multi-agency meeting did not take place prior his discharge from hospital. The plan for Mr Savory’s care, support and treatment in respect of his substance misuse, physical health, mental health and social care needs is unclear. Mr Savory’s presentation declined in the community. Safeguarding referrals were made but no multi agency meetings were convened pursuant to safeguarding duties under the Care Act or as per the Kent and Medway Multi-Agency Policy and Procedures to Support People that Self-Neglect or Demonstrate Hoarding Behaviour. Police made entry into Mr Savory’s home address on 13 December 2019, he was found to be deceased. Toxicological evidence indicated that Mr Savory had taken a lethal dose of methadone. There was no evidence that Mr Savory had intended to take an overdose. 5 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 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. – (1) There was no evidence of a multi agency planning meeting prior to Mr Savory’s discharge from Queen Elizabeth The Queen Mother Hospital on 25 September 2019. Nor was there evidence of what multi-agency procedures are in place relating to the safe discharge of patients with concurrent, mental health, substance misuse, social care and physical health needs; 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe 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 6 October 2021. 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 The family of Hadley John Savory The Director of Adult Services at Kent County Council The legal representatives of the above. In addition, I have sent this to: The Independent Chair of the Kent and Medway Safeguarding Adults Board 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 Signature: Ian Brownhill Assistant Coroner North East Kent 11 August 2021
See every Prevention of Future Deaths report matching East Kent Hospitals University NHS Foundation Trust, 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.