Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0190, written 11 Jun 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 11 Jun 2023 |
|---|---|
| Reference | 2023-0190 |
| Deceased | Marlene McCabe |
| Coroner | Timothy Holloway |
| Coroner area | Blackpool & Fylde |
| Category | Other related deaths |
| Organisation named | Lancashire & South Cumbria NHS Foundation Trust · Blackpool Teaching Hospitals 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.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1)
NOTE: This form is to be used after an inquest.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
(i) Bloomfield Medical Centre;
(ii) Blackpool Teaching Hospitals NHS Foundation Trust;
(iii) Lancashire and South Cumbria NHS Foundation Trust;
(iv) North West Ambulance Service.
1
CORONER
I am Timothy R Holloway, Assistant Coroner for the area of Blackpool & Fylde
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 5 September 2019 an investigation was commenced into the death of
Marlene McCabe. An inquest was opened on 10 September 2019. The
investigation concluded at the end of the inquest held at Blackpool Town Hall on
6 March 2023 - 23 March 2023 and 3 May 2023.
Conclusion of Investigation (Section 4)
Unlawful killing.
On 4th September 2019, between around 5.10pm and 5.50pm, Marlene
McCabe was killed unlawfully in her own home. She died as a consequence of
being struck a multiplicity of times to the head and face with a blunt object,
namely, a doorstop, which occasioned catastrophic head and facial injuries. The
actions of her assailant were more than minimally contributed to by the
assailant's undiagnosed and untreated schizophrenia coupled with alcohol
intoxication.
Cause of death:
1 (a) Severe blunt force head and facial injuries.
4
CIRCUMSTANCES OF THE DEATH
Box 3 of the Record of Inquest recorded as follows:
On 4th September 2019, between around 5.10pm and 5.50pm, Marlene
1
McCabe was killed unlawfully in her own home. She died as a consequence of
being struck a multiplicity of times to the head and face with a blunt object,
namely, a doorstop, which occasioned catastrophic head and facial injuries. The
actions of her assailant were more than minimally contributed to by the
assailant's undiagnosed and untreated schizophrenia coupled with alcohol
intoxication. There were accepted prior failures in the collation and consideration
of information, including from the available records and family, and in the mental
health assessment of and progression of treatment for the assailant, in particular
from early July 2019, which did not more than minimally contribute to Marlene
McCabe's death.
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 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:
A. To:
(i) Bloomfield Medical Centre
(ii) Blackpool Teaching Hospitals NHS Foundation Trust
(iii) Lancashire and South Cumbria NHS Foundation Trust
1) There remains the potential for a lack of understanding amongst
clinicians as to how urgent referrals into the PIMHT should be
made.
B. To:
(i) Bloomfield Medical Centre
(ii) Blackpool Teaching Hospitals NHS Foundation Trust
(iii) Lancashire and South Cumbria NHS Foundation Trust
(iv) North West Ambulance Service
2) There is inconsistent availability of access to mental health
records across the service providers and information sharing
between service providers using different data bases is difficult.
C. To:
(i) Blackpool Teaching Hospitals NHS Foundation Trust
(ii) Lancashire and South Cumbria NHS Foundation Trust
3) There is a residual risk that reference to drug and/or alcohol
misuse in mental health referrals and/or assessments may lead
2
to
that
the missing of a mental health diagnosis and
circumstances may arise in which assumptions are made
concerning substance misuse.
D. To:
(i) Bloomfield Medical Centre
(ii) Blackpool Teaching Hospitals NHS Foundation Trust
(iii) Lancashire and South Cumbria NHS Foundation Trust
4) There is a residual risk of non-communication of material
to patients’ mental health between
information pertaining
healthcare providers.
E. To:
(i) Blackpool Teaching Hospitals NHS Foundation Trust
(ii) Lancashire and South Cumbria NHS Foundation Trust
5) There is a risk that delayed assessment of patients who may
appear to be or are reported to be intoxicated will give rise to a
loss of opportunity to identify signs of psychosis.
6
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe your
organisations 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 7th August 2023. 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:
(i) The family of Marlene McCabe
(ii)
, Bloomfield Medical Centre
3
(iii) Chief Constable of Lancashire Constabulary
I am also under a duty to send the Chief Coroner a copy 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
TR Holloway
Assistant Coroner for Blackpool & The Fylde
Dated: 11th June 2023
4
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