Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0367, written 29 Sep 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 29 Sep 2023 |
|---|---|
| Reference | 2023-0367 |
| Deceased | Leighton Dickens |
| Coroner | David Regan |
| Coroner area | South Wales Central |
| Category | Mental Health related deaths · Child Death (from 2015) |
| 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.
ANNEX A
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:
The Chief Constable of South Wales Police
1 CORONER
I am David Regan, Assistant Coroner, for the coroner area of South Wales
Central.
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
A Coronial investigation was commenced on 27th October 2020 into the death
of Leighton Alan Dickens. The Investigation concluded at the end of the
inquest which I conducted with a jury on 18th – 28th September 2023. The
conclusion was a narrative conclusion and the medical cause of death was 1 (a)
pressure on the neck (incomplete or atypical hanging)
4 CIRCUMSTANCES OF THE DEATH
These were recorded as: -
Leighton Dickens died by incomplete atypical hanging alone in his home
address on 14th October 2020.
The narrative conclusion which the Jury returned was:
Leighton Dickens died by hanging himself in circumstances where his
intention could not be ascertained. It is the juries understanding, that it was a
1
missed opportunity on the part of the police not to detain Leighton Dickens at
hospital until he had been assessed by a Mental Health Professional.
The Inquest focused upon: -
a. Mr Dickens’ mental health condition and behaviour on the night of his
death.
b. The fact that police officers came upon him by the side of the road in
an undressed state in the presence of his partner who was trying to
convey him to hospital.
c. His presentation and behaviour towards the officers before during and
after arrival at hospital
d. The decision by officers not to invoke their powers under s. 136 Mental
Health Act and to leave Mr Dickens at hospital in circumstances in
which they knew that he had not been subject to medical assessment
and intended to leave.
e. The limited sources of support available to assist or guide the officers.
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. –
(1) Following the withdrawal of the mental health triage support provided
to the police by mental health nurses, the medically qualified sources of
urgent support available to police officers to assist them to safeguard
the public are limited to the mental health crisis teams.
(2) The crisis teams may not be readily available and deal with their own
case load.
(3) The alternative support available from a mental health tactical adviser,
is not provided by a clinically qualified member of staff and does not
have access to the PARIS mental health records system.
(4) The intended replacement of the mental health triage support was to
have been by the “111 press 2” service. This has not been put in to
place and there is no current timescale for it to be put into place.
2
(5) This leaves officers with limited sources of qualified mental health
advice, with access to relevant clinical records, when responding to the
risks posed by those suffering from mental health crisis within the
community
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 24th November 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 family who may find it useful or of interest.
Welsh Government, Medical Director of the Cwm Taf Morgannwg University
Health Board, Medical Director of the Cardiff and Vale University Health
Board, Medical Director of the Swansea Bay University Health Board.
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
29th September 2023 SIGNED:
D Regan
Assistant Coroner
3
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