Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0222, written 25 Apr 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 25 Apr 2024 |
|---|---|
| Reference | 2024-0222 |
| Deceased | Erik Marshall |
| Coroner | Marilyn Whittle |
| Coroner area | South Yorkshire (West) |
| Category | Child Death (from 2015) · Suicide (from 2015) |
| 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: NHS Cheshire and Merseyside Integrated Care Board 1 Lakeside 920 Centre Park Square Warrington, WA 1 1 QY. 1 CORONER I am Marilyn Whittle, assistant coroner, for the coroner area of South Yorkshire (West) sitting in Cheshire Coroners Court 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 18 October 2023 an investigation was commenced into the death of Erik Leigh Marshall, a 17 year old male born in Warrington. The investigation concluded at the end of the inquest on 25 April 2023. The conclusion of the inquest was death by misadventure. The medical cause of death was: 1a. Asphyxiation 1b. ligature hanging 2 ASD ADHD anxiety. 4 CIRCUMSTANCES OF THE DEATH Erik Marshall died on 30 September 2023 at his home address in Cheshire. He was found suspended by a ligature . Prior to this he had suffered from ADHD, mental health issues and had recently received a clinical diagnosis of autism. Erik's sensory needs and mental health presentation meant that he habitually partly drowned himself in the bath to experience a buzz and the feeling of numbness in his arms and legs. Erik's mental health needs were being treated in the community following an inpatient admission at ancorra house and the Priory. During admission to the Priory Erik was clinically diagnosed with autism . Following discharge from the Priory the plan was to obtain a sensory assessment through OT in the community to help him with the high risk sensory behaviours. The Child Development Centre (CDC), part of Bridqewater Community Healthcare NHS Trust, were invited to the CPA meetings and were aware of Erik. Referrals were made to the CDC for an ADOS assessment and OT input in May 2023. The CDC responded to state they did not require an ADOS assessment to provide the support but they did want to review the assessment undertaken at the Priory to see if this complied with NICE guidance before any referral to their nurses was made. They also made a decision, based on the limited information that they had been provided and without speaking to any clinician or family member, that Erik's mental health need was more prominent than the sensory need. The CDC were still waiting for further information regarding the autism assessment in the Priory in August 2023, yet made no attempt to chase this up. I received evidence that escalations were made for specialist input for his sensory needs because it was identified without this it was likely to deteriorate and his risk increase. The OT referral was not accepted because of Erik's age and that whilst he was signposted to adult services these would only assist when he was 18 because there was a commissioning gap. Following escalation to the ICB specific funding was put in place for access to the sensory hive for Erik but the initial appointment only occurred on 22 September 2023 and Erik was found deceased in the back garden of his home 8 days following this. 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 could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. - I was provided with evidence that the OT referral made to the Chi ld Development Centre in Warrington was not accepted because Erik was 17 years old and they were only commissioned to age 16. I was informed that there was no provision in comm issioning for new OT referrals for sensory needs and that he was signposted to possible adult services although these would only accept him once he was 18. A gap in the commissioning and support for these high risk individuals was identified. 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 20 June 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 2 I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: Warrington Borough Counsel Bridgewater Community Healthcare NHS Trust. 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 25/04/2023 Marilyn Whittle - 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.
14 June 2024 Dear Mrs Whittle M Whittle HM Assistant Coroner (South Yorkshire West) Sitting at Cheshire Coroners Court Re: Regulation 28 Prevention of Future Deaths Notice - Erik Leigh Marshall Thank you for your letter dated 25th April 2024 sent following the conclusion of your inquest into the death of Erik Leigh Marshall. I understand that you will share our response with Eriks family, and I wish to pass on our sincere condolences for their loss. Through the Regulation 28 letter you have raised a concern which involves NHS Cheshire and Merseyside Integrated Care Board. Following the investigation and inquest into the death of Erik Leigh Marshall it has been requested by yourself what provisions will be put in place to address the commissioning gap for ‘Occupational Therapy’ (OT) services for 16–18-year-olds in Warrington. NHS Cheshire & Merseyside Integrated Care Board recognise this gap in provision and in response to this request can confirm the following action: Our Cheshire and Merseyside Commissioning Board (C&M ICB) intends to commission the Occupational Therapy service for Children and Young People up to the age of 18 years and 364 days. This will be in place from December 2024. The current service offer for children up to the age of 16 is listed below, from December this offer will be available to young people until the day before their 19th birthday (when they will transition to the adults service). • Assessment and advice for children and young people with sensory processing difficulties/ sensory integration. • Specialist advice and training on therapy interventions for parents and carers where clinically appropriate. • Specialist therapy for assessment, treatment, and advice for children and young people with complex health needs as indicated by clinical requirement. • Young people will be supported in the transition to adult services and a transition plan is in place. • A service which is fully aware of and involved in safeguarding processes for children and • young people. Involvement and Engagement with children, young people, and their families (the service will develop innovative, accessible methods of engaging with service users and gaining their feedback and they will report on this at regular intervals.) • Collection and evaluation of feedback from children, young people, and parents/carers on informing the design and delivery of the local health services for them. • Work towards relevant accreditations and standards as described in national and local guid- ance. • Specialist therapy for assessment, treatment and advice in maximising Motor Skills and ac- tivity programmes to maximise children’s functionality levels in everyday activities. NHS Cheshire and Merseyside No 1 Lakeside, 920 Centre Park Square Warrington, WA1 1QY Communications@cheshireandmerseyside.nhs.uk Cheshireandmerseyside.nhs.uk • Assessment and recommendation of equipment for schools and nurseries only e.g. toileting and seating. • Assessment and recommendation of children requiring orthotic provision to Warrington and Halton Hospital Financial Trust, or appropriate provider. NHS Cheshire and Merseyside Integrated Care Board are deeply saddened by the death of this young person and hope this provides a satisfactory response to the request. I am grateful to you for raising these issues with the NHS Cheshire and Merseyside ICB and I hope that this response has addressed the concerns raised. Should you require any further clar- ification or information, please do not hesitate to contact me. Yours sincerely Executive Director of Nursing & Care NHS Cheshire and Merseyside No 1 Lakeside, 920 Centre Park Square Warrington, WA1 1QY Communications@cheshireandmerseyside.nhs.uk Cheshireandmerseyside.nhs.uk
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