Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0195, written 16 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 | 16 Jun 2023 |
|---|---|
| Reference | 2023-0195 |
| Deceased | Girmaye Guyo |
| Coroner | Zak Golombeck |
| Coroner area | Manchester City |
| Category | Other 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. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: • The Rt Hon Steve Barclay, MP, Secretary of State for Health and Social Care • Mr Alex Chalk KC, MP, Lord Chancellor and Secretary of State for Justice Copied for interest to: • Chief Coroner • Parents of the Deceased • Greater Manchester Mental Health NHS Foundation Trust • Royal College of Psychiatrists 1 CORONER I am Mr Zak Golombeck, Area Coroner for Manchester (City) Area 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 INQUEST I concluded the inquest into the death of Girmaye Guyo Liban on 17th May 2023 and recorded that he died from: 1a Drowning I returned an Open conclusion following investigations. 4 CIRCUMSTANCES OF THE DEATH The Deceased had a long history of mental health illness and substance abuse. Between 4th June 2020 and 15th September 2020 he was detained pursuant to the provisions of Mental Health Act 1983 at Eagleton Ward, Meadowbrook Unit. The Deceased's discharge from Eagleton Ward was authorised via his mother using her Nearest Relative Powers pursuant to the provisions of Mental Health Act 1983, and its associated Code of Practice. The Deceased then returned to the family home. The evidence that I heard at the Inquest was such that the Deceased was still liable to be held under Section 3 Mental Health Act 1983; however, due to the difference in the test being applied for consideration of an application by a Nearest Relative, there 1 was no choice but to discharge the Deceased Further evidence alluded to the concerns from clinicians about this power, and although the evidence was that it is seldomly used, it presents an opportunity for patients and families to deviate from the clinical course prescribed by clinicians. There was no consideration for a Community Treatment Order for the Deceased as the provisions of the legislation refer to discharge from detention. The Deceased remained unwell in the community, and on 10th November 2020 he went missing. His body was found in a local reservoir on 26th November 2020. There was insufficient evidence to determine how he came to enter the water. 5 CORONER'S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there 1s a risk that future deaths will occur unless action is taken In the circumstances it is my statutory duty to report to you. The MATTER OF CONCERN is as follows: The Nearest Relative Power may (as it did in this case) present an opportunity for a patient and/or their Nearest Relative to apply to the Responsible Clinician for discharge in circumstances when the patient remains liable for their continued detention There does not appear to be a thorough procedure or legal test for clinicians to apply, and thus there is a risk that Responsible Clinicians may be faced with circumstances whereby a patient will be discharged from hospital despite them continuing to meet the criteria for detention. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you and 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 Friday 11 th August 2023, 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 Interested Persons. I have also sent it to organisations who may find 1t useful or of interest. I am also under a duty to send the Chief Coroner a copy of your response. 2 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 1t 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: NAME OF CORONER: Friday 16th June 2023 Signed: Zak Golombeck HM Area Coroner for Manchester City Area 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.
From Maria Caulfield MP Parliamentary Under Secretary of State Department of Health & Social Care 39 Victoria Street London SW1H 0EU 9 May 2024 Mr Zak Golombeck HM Area Coroner for Manchester City Area Manchester City Coroner's Court Exchange Floor 514-516 The Royal Exchange St Ann's Square Manchester M2 7EF Dear Mr Golombeck, Thank you for your Regulation 28 report to prevent future deaths dated 16 June 2023 about the death of Girmaye Guyo Liban. I am replying as Minister with responsibility for Mental Health. Firstly, I would like to say how saddened I was to read of the circumstances of Mr Liban and I offer my sincere condolences to their family and loved ones. The circumstances your report describes are concerning and I am grateful to you for bringing these matters to my attention. Please accept my sincere apologies for the significant delay in responding to this matter. The report raises concerns over the use of provisions in the Mental Health Act 1983 for a person’s Nearest Relative to exercise their power to seek the discharge of a patient. In this case you believe that this discharge was not in accordance with the patient’s continuing need for clinical care. In responding to the matter you have raised, I should say firstly that section 25 of the Mental Health Act does give the patient’s Responsible Clinician powers to bar such requests for discharge. As set out in the Act’s Code of Practice (32.21-22), before giving a discharge order, the Nearest Relative must give the hospital managers at least 72 hours’ notice in writing of their intention to discharge the patient. During that period, the patient’s responsible clinician can block the discharge by issuing a ‘barring report’ stating that, if discharged, the patient is likely to act in a manner dangerous to themselves or others. If a Nearest Relative’s discharge is barred they are not able to apply again for six months. The Government does not intent to amend the Nearest Relative powers of discharge as, although they are rarely used, they do provide an important safeguard for patients and their families. Nevertheless, the tragic case you have raised with me, indicate that patient safety is paramount, and I regret that for Mr Liban the outcome was so tragic. I hope this response is helpful. Thank you for bringing these concerns to my attention. Yours sincerely, MARIA CAULFIELD
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