Georgia Dehaney-Perkins

28 March 2024 

Private and Confidential  

Ms Sonia Hayes   
HM Area Coroner for Essex Coroner’s Office    
Seax House Victoria Road  
Essex  
South Chelmsford  
CM1 1QH   

Chief Executive Office 

                   The Lodge 
          Lodge Approach 

Wickford 
SS11 7XX 

Dear Ms Hayes, 

Georgia Gypsy Catherine Dehaney-Perkins (RIP) 

I write to set out the Trust’s formal response to the report made under paragraph 7, Schedule 5, of 
the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) 
Regulations 2013, dated 5th February 2024 in respect of the above, which was issued following the 
inquest into the death of Ms Dehaney-Perkins. 

I would like to begin by extending my deepest condolences to Ms Dehaney-Perkins’ family. The 
Trust sympathises with their very sad loss.  

The matters of concern as noted within the Regulation 28 Report have been carefully reviewed and 
noted. I will now respond in full to these concerns in the hope that this provides both yourself and        
Ms Dehaney-Perkins’ family with comprehensive assurance of changes that have been made at the 
Trust to address the concerns you have raised. 

Concern 1) On 28 August Ms Dehaney-Perkins was agitated and distressed on return to the ward 
from leave and had consumed alcohol that was known to increase her risk of self-harm. Ms 
Dehaney-Perkins tied a ligature to this assisted toilet bar and hanged herself. Staff found Ms 
Dehaney-Perkins and removed the ligature.   

a)  Ms Dehaney-Perkins was admitted to a room with an assisted bathroom (this was not a 

requirement for her) with a fault in the anti-ligature safety mechanism meant that the safety 
feature could not be implemented.  

b)  There was no risk assessment about the suitability of this room for Ms Dehaney-Perkins a 

patient with a self-harming history at the time of the admission.  

c)  The fixed-point ligature was not appropriately updated in the risk assessment and was not 

discussed at a discharge planning meeting.  

d)  The Trust Datix Report was incomplete 

Response: All patients have a risk assessment completed within four hours of admission to the 
ward.    This is monitored through the clinical dashboard daily by the Nurse in Charge.  On 
admission the Nurse in Charge will delegate duties to ensure that all admission tasks are completed.  
Prompts have been added to the ward diary to remind staff to check that all tasks including risk 
assessments have been completed. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
      
 
 
 
 
 
 
 
 
 
    
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
         
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
      
 
 
 
 
 
 
 
 
 
 
 
 
   
    
      
         
 
 
 
 
 
 
 
 
 
 
 Cherrydown Ward has two assisted bathrooms which have reduced ligature handrails.  To reduce 
the risk of patients allocated to those rooms, the risks are documented in individual risk 
assessments and care plans.  If a patient is at significant risk of self-harm the ward would attempt to 
relocate patients to ensure that any high risk patients are not allocated the assisted bathroom 
bedrooms.  This will also be discussed in 1:1 support supervision and the monthly meetings with all 
qualified staff to ensure that this is taking place.  Documentation will be audited at the 1:1 support 
supervision’s with those staff that have patients allocated the assisted bathroom bedrooms. 

There is a prompt on the handover sheet to ensure that the Nurse In-Charge checks the handrails 
mechanism remains in a locked and upright position.  This is checked and signed for every shift.  
Regular audit and assurance are completed by the Ward Manager and Ward Clerk to check that this 
is being completed.  Regular inspections of all room fixtures including handrails are done as part of 
Ligature audits to ensure compliance with EPUT safety protocols.   

Thorough risk assessments are being carried out using EPUT risk assessment tools including 
suitability of rooms for all patients on admission. There is collaboration with mental health 
professionals, including psychiatrists, psychologists, community mental health nurses, GP’s and 
social workers to gather comprehensive information regarding the patient’s history of self –harm and 
associated risk factors. 

The General Workplace Risk Assessment has been updated to include the fixed-point ligature. 
Multi-disciplinary team discussions are being undertaken to develop and to review individualised 
care plans and risk assessments as part of discharge planning. 

The Matron has made urgent contact with the risk management team in relation to the Datix Report 
for this matter – the datix report was approved by the Patient Incident Team on 26th March 2024. A 
further review of the process is being undertaken to improve sign off where there is a patient safety 
incident.  

Concern 2) Medication was appropriately withheld on 28 August when Ms Dehaney-Perkins 
returned to the ward intoxicated due to potential interaction with alcohol that can cause increased 
sedation,  

Response:  The Trust notes the above finding by HM Area Coroner.  

Concern 3) Arrhythmia and fatality  

a)  This risk of consuming alcohol with her specific medication was not discussed with the Ms 

Dehaney-Perkins or family.  

b)  Not all incidents of consumption of alcohol on return from leave were recorded and risk 

assessments were not updated.  

c)  Ms Dehaney-Perkins had agreed to mitigations of medication management by her family that 
were not recorded on the care plan on discharge on 2 September. Ms Dehaney-Perkins 
demanded control of her medication on 4 September against concerns of her family who 
were forced to return medication.  

Response: If a patient is identified as at high risk of alcohol misuse they are referred to the Drug 
and alcohol service.  It is also discussed with the patient advising them of the risks of using alcohol 
whilst on medication.  Where consent is given family are invited to ward reviews and discharge 
planning meetings and discussion around medication, risks and compliance is part of those 
meetings.  This is documented in the patients’ notes. 

A risk assessment is completed prior to a patient going on leave.  Upon the patient returning from 
leave one to one engagement is offered to the patient, if any incident has occurred whilst the patient 
has been on leave this is reported via Datix and the risk assessment is updated accordingly.  The 
incident is also documented within the patients’ notes and information is shared with all health 
professionals involved in the care of the patient during handover, Multidisciplinary Team meetings 
and ward reviews. 

 
 
 
 
 
 
 
 
 
 
 
 In order to strengthen safety measures in relation to this concern the wards now have in place that 
post each discharge meeting, discharge plans are shared with all health professionals and 
family/carers (with consent) involved in the care of the patient.  A prompt is now written in the diary 
to remind staff to check the discharge plan that has been agreed for that patient including 
medication plans. 

Concern 4) The Home First Treatment Team attended a scheduled appointment on 4 September 
and Ms Dehaney-Perkins appeared stable and updated the risk assessment that the risk of self-
harm remained significant when alcohol was consumed. No action was taken following a call raising 
some queries and concerns from family that evening that Ms Dehaney-Perkins had left her home 
with her medication.  

Response: The Home First Team will support patients and carers when they contact the team 
raising concerns around risk. The patient will be contacted by a member of the team who will 
explore the concern and manage it accordingly.   

Where it is clear that there is an imminent risk to the person or to others, the Home First Team may 
consider requesting urgent police assistance to support with keeping the patient safe. 

Where there is no imminent risk indicated, and the Home First Team are unable to make contact, 
the team will feed back to the carer to inform them that no contact has been made, however every 
effort has been made to contact the patient.  Where this person is known to EPUT services the 
relevant team will be notified to provide follow up for the patient. 

If the carer has identified risk that is deemed to require further assessment / intervention, the Home 
First Team may consider whether a home visit is warranted and “cold call” the individual.  This would 
be also with the assistance of the Crisis 24 Team where appropriate. All staff have been reminded 
about ensuring that they work according to trust policy and this has been discussed in the business 
meetings. Assessments and clinical notes are reviewed with individuals during their one to one 
supervision to focus on the quality of their record keeping including risk assessments. 

I hope that I have provided reassurances around the steps that we have taken to address the issues 
of concern contained within your report. We appreciate that there is an acute need to embed and 
effect change, hence we will monitor the above provisions to ensure these are contributing to our 
overall aim of keeping patents safe and delivering therapeutic care. 

Please do let me know if you require any further information at this stage, including copies of any of 
the documents referred to above. 

We will await your direction before sharing a copy of this reply with the family / the CQC as required. 

Yours sincerely, 

Chief Executive