Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0150, written 12 May 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 12 May 2023 |
|---|---|
| Reference | 2023-0150 |
| Deceased | Odessa Carey |
| Coroner | Andrew Hetherington |
| Coroner area | North Northumberland and South Northumberland |
| Category | Other related deaths |
| 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.
ANDREW HETHERINGTON
H M Senior Coroner for North Northumberland and
Acting Senior Coroner for South Northumberland
County Hall, Morpeth, Northumberland NE61 2EF
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
Chief Executive of Cumbria, Northumberland, Tyne and Wear NHS
·Foundation Trust
1 CORONER
I am Andrew Hetherington, Senior Coroner for North Northumberland and Acting
Senior Coroner for South Northumberland.
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.
http://legislation.gov .uk/ukpga/2009/25/schedule/5/paragraph/7
http://www.legislation.gov .uk/uksi/201 3/1629/part/7 /made
3
INVESTIGATION and INQUEST
On 10 April 2019 HM Senior Coroner Tony Brown commenced an Investigation
into the death of Odessa Carey who was born on 20 May 1945 and who died
within
suspended the investigation under Schedule 1 of the CJA as he was informed
on 15 April 2019 that an individual had been charged with a homicide offence of
murder.
pn 8 April 2019. He adjourned and
On 11 March 2020 the perpetrator was found to have comm itted Murder and
sentenced under Section 38 Hospital Order with a Section 41 Restriction.
I made the decision to resume the Inquest, as there was sufficient reason to do
so as the perpetrator had been involved with mental health services for an
extensive period of time and was still open to services at the time of Odessa
Carey's death.
The conclusion of the inquest was "Unlawfully killed".
The medical cause of death was 1 a Blunt force head injury.
4
CIRCUMSTANCES OF THE DEATH
Odessa Carey was last seen alive on the evening of Thursday 4th April 2019
, Ashington. She was attacked by the
within her home address
perpetrator. On 7th April 2019 the police have attended
and found the body of the deceased covered with bedding sheets. The body
was without the head. Police officers have then attended another address and
following a systematic search of that property, the perpetrator was found and
arrested in connection with the murder of the deceased.
, Ashington
On 11 March 2020 the perpetrator was found to have committed Murder and
sentenced under Section 38 Hospital Order with a Section 41 Restriction.
I resumed the Inquest as there was sufficient reason to do so as the perpetrator
had been involved with mental health services for an extensive period of time
and was still open to services at the time of Odessa Carey's death.
5 CORONER'S CONCERNS
During the course of the inquest 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. Multi-agency Risk Assessment Conference ("MARAC")
I heard evidence of issues of assault, violence and intimidation. Further that the
consent of the individual reporting the concerns is not always required in order
to complete a MARAC referral.
Whilst I recognise that the extent of the issues could have been diminished out
of fam ilia I ties or for other reasons, I am concerned that that staff did not explore
the issues to a greater extent with the deceased, the wider family and other
agencies.
2. Assessment of substance misuse
The service user had a history of substance misuse in particular cannabis and
its impact on mental health was recognised.
Whilst I acknowledge issues regarding service user consent and compliance, I
am concerned there was no referral to substance misuse services for advice or
assessment and treatment whilst an inpatient or in the community.
3.
Inpatient discharge 30 May 2018
The discharge was not a coordinated discharge in line with the trust CPA policy.
There was no discharge meeting, no involvement with other agencies or family,
the service user was still mentally unwell, having delusional beliefs, without
supported accommodation, vulnerable, moving to a new locality and without
familial support
I am concerned there was a lack of opportunity to involve the family or other
agencies in the discharge.
I am concerned that there was no direct contact or introduction to the service
user from the care coordinator whilst an inpatient or before discharge to
establish a relationship and trust.
4. Discharge from the Community Treatment Team on 6 Au_gust 2018
There was no pre-discharge meeting in line with trust CPA Policy involving the
family, lead professionals, other agencies or a Consultant Psychiatrist for future
planning.
A more assertive approach to engagement may have been appropriate.
I am concerned that following discharge from the Lowry ward to the community
and prior to discharge from the community treatment team, the deceased was
seen only four times in person by individuals from the mental health team and
only once by the care coordinator.
I am concerned that more intense, in person engagement was warranted and
discharge from the Community Treatment Team was premature.
I am concerned that the service user was not seen by a Consultant Psychiatrist
at all after 30 May 2018 despite enquiring about a further appointment.
5. Appointment of a Care Coordinator
I heard that in line with the trust CPA policy paragraph 12.1 "Consent must
always be sought from a professional prior to them being identified as a Care
Coordinator. Under no circumstances must any professional be stated as Care
Coordinator without negotiation and agreement. "
I am concerned that consent and agreement was not obtained from a care
coordinator prior to being identified for the role of care coordinator and concerns
regarding capacity were not considered.
6. FACE Risk assessment tool
I am concerned that there continues to be an inconsistent approach to the
assessment of risk. Various methods are still being deployed and there is a
possibility of a disparity in the understanding of the risk to the service user and
others.
7. Record Keeping Documentation
I am concerned that entries in the RiO medical records were not made in line
with Trust guidance in a timely, complete manner or at all.
I am concerned that evidence of clinical assessment, care planning and the
reasoning behind clinical decision making were not recorded.
8. Contact with !RT and referral to Community Treatment Team
The service user contacted the service on a number of occasions and sought
self-referral to the Crisis team on 19 September 2018 who assessed her as
requiring a re-referral to the community team. No referral was made.
I am concerned that there was a delay in the referral to the Community
Treatment Team and there is no audit system to ensure referrals are made and
in a timely fashion.
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
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 The family of Odessa Carey Deceased
I am also under a duty to send the Chief Coroner acopy of your response. 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
Date\').~ Signed:
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Andrew Hetheri gton HM Senior Coroner or North No umberland and Acting
Senior Coroner for South Northumberland
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