Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0273, written 17 May 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 17 May 2024 |
|---|---|
| Reference | 2024-0273 |
| Deceased | Lily Jahany |
| Coroner | Fiona Butler |
| Coroner area | Leicester City and South Leicestershire |
| Category | Suicide (from 2015) |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: Student Roost Leicestershire Partnership Trust 1 CORONER I am Miss F BUTLER, His Majesty's Assistant Coroner for the coroner area of Leicester City and South Leicestershire. 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 16 December 2022 I commenced an investigation into the death of Lily Precious JAHANY aged 18. The investigation concluded at the end of the inquest on 17 May 2024. The conclusion of the inquest was that: Lily Precious Jahany was an 18 year old university student. She was a bright intelligent girl, who was studying to become a Doctor. She resided in student accommodation in Leicester and had been in the city for a period of only 3 months at the time of her death. Lily had a diagnosis of bipolar affective disorder, but also was suffering from post traumatic stress disorder, depression and anxiety, had an underlying eating disorder and whilst not diagnosed with autistic spectrum disorder, demonstrated certain traits associated with the condition, such as rigid thinking and perfectionism. Lily had a lengthy and complicated psychiatric history which was not fully appreciated by those clinicians whose care she came under during her time in Leicester due the lack of a single national medical record for patients, but also the fact that Lily was treated within the private sector. This had the impact of misleading those who treated Lily in the assessment of her risk. But conversely, placed upon them a greater duty and emphasis on ensuring they had at their disposal the relevant information to be able to properly and fully assess Lily’s risk, which they failed to do. At the time of her death Lily had been closed to the Crisis Team and was awaiting assessment by the Community Mental Health team for a medication review by a psychiatrist. 3 weeks prior to her death Lily started to suffer manic episodes connected to her bipolar affective disorder. She took 3 overdoses and attempted to ligature on two occasions. Lily would decline hospital admission by the emergency services who attended on her, including on the 8th December 2022, when she was found to be ligating in her room in her student accommodation and paramedics and the police were called. On the 9th December 2022, Lily was found by Regulation 28 – After Inquest Document Template Updated 16/05/2023 accommodation staff in her room suspended by a ligature around her neck. Emergency services were called, but Lily was declared deceased at 12.35 hours The cause of death was established as: I a Suspension by ligature I b I c II 4 CIRCUMSTANCES OF THE DEATH 1. Lily Precious Jahany was an 18 year old medical student who had an extensive background history of mental health difficulties starting as early as the age of 7. She also had an extensive history of previous self harm. Lily was diagnosed with Bipolar Affective Disorder and was treated with Fluoxetine and Lurasidone and had input from a of counsellor. 2. Lily was a highly complex young lady and in addition to her diagnosis of Bipolar Affective Disorder had underlying diagnosis of post traumatic stress disorder caused by the childhood trauma, depression and anxiety. Although not positively on the autistic spectrum disorder, Lily also demonstrated autistic spectrum disorder traits and had an underlying eating disorder. 3. Lily started Leicester University in September 2022. By mid November 2022, Lily started to experience manic episodes connected to her bipolar symptoms and reported taking 3 overdoses on 15, 16 and 18 November. Lily refused to seek medical attention and when she did present to A&E on the 18th discharged herself before being assessed by the Mental Health team. 4. Lily’s maladaptive behaviors escalated further and she ligated on 1st December 2022 and again on the 8th December 2022. In the week in between there were other episodes which could be construed as self harm through not eating necessitating ambulances to be called. 5. The extent of Lily’s mental health difficulties were not fully appreciated when she arrived in Leicester due to not only the absence of a national single electronic patient record but also because Lily was treated in the private sector and records held by private clinicians are not accessible within a national SystmOne record keeping system. 6. This in my judgment had the impact of misleading those who treated her in the assessment of Lily’s risk. But conversely, placed upon them a greater duty and emphasis on ensuring they had at their disposal the relevant information to be able to properly and fully assess Lily’s risk. 7. There were failures to obtain the full extent of Lily’s mental health challenges and seek information which was pertinent to the assessment of her risk. However, whilst I find there were failures I cannot find on balance that those failures more than minimally trivially or negligibly contributed to Lily’s death. 8. At a time unknown between 11pm 8th December 2022 and midday on the 9th December 2022 Lily took increased doses of Zopicone and Promethazine and tied a ligature around her neck and she did so intending to die as a result of her actions. 9. Lily was pronounced deceased at 12.35 hours on the 9th December 2022. Regulation 28 – After Inquest Document Template Updated 16/05/2023 5 CORONER’S CONCERNS During the course of the investigation my inquiries 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: (brief summary of matters of concern) (1) Lily resided at student accommodation provided by Student Roost. They describe themselves on their website as ‘a student accommodation provider who puts your wellbeing first. Our aim is to provide the very best experience for you to make the most of student living. Since they were established in 2017, Student Roost has grown to offer 50+ properties across the UK. Student Roost run a 24/7 service including a Night Owl Service which is an excellent idea and provides a 24 hour service to help students with everything from loosing their keys, broken taps, but also their wellbeing. During the course of hearing evidence, it is evident that all of Lily’s extreme acts of self-harm took place at her student accommodation. She took at least 3 overdoses and also carried out 2 acts of ligating which she had to be either untied or cut down from. One of those I heard required CPR. I am therefore surprised to learn that no staff (certainly in the 6 properties offering accommodation within Leicester) had first aid training and that it isn’t mandatory, such that no staff are trained by Student Roost in first aid. It transpires therefore that any immediate first aid provided to Lily was provided by those who fortuitously had that training from other organisations before they joined Student Roost. In the context of this case but also wider than that, members of the accommodation staff could potentially be the first people at the scene of a situation requiring first aid and then emergency services; where death may occur the fact therefore that they receive no training concerns me. (2) I have spent a lot of time in this inquest investigating the information which was known about Lily, about her mental health and who had access to what information in the context of assessing her risk. In September of 2023, Miss Evans, Assistant Coroner sitting within the Rutland and North Leicestershire jurisdiction heard an inquest concerning a student at Loughborough University. Similar to Lily’s case he was under the care of a private psychiatrist elsewhere in the country where he had lived prior to attending university. As a result of concerns in that case (his death occurring 1 year before Lily’) around lack of contact by the Crisis Team at the time of assessment or otherwise with the private psychiatrist, the Coroner wrote to the Leicestershire Partnership Trust to share her concerns. The Trust referenced the Crisis Team Standard Operating procedure in the inquest in September 2023, the Coroner was concerned about the level of awareness that staff members had of any expectation required of them set out within that procedure to seek information from other agencies. I now have sight of the Cris Team Standard Operating Procedure. It sets out the keyworker responsibilities. The section is drafted presupposing that patients are receiving care and treatment from the Crisis Team and only at that point does the responsibility for seeking relevant information from other agencies kick in. Furthermore the emphasis upon that requirement is limited to one line which reads ‘responsibility for referrals and liaising with other agencies involved’. That is anything but clear as to any expectation upon staff to ensure they have at their disposal all of the relevant risk information at the time of making that assessment; nor does it in my view set out any expectation upon staff to proactively Regulation 28 – After Inquest Document Template Updated 16/05/2023 make contact with treating clinicians in the private sector to gain information. It would not capture situations such as Lily’s, who was discharged from the Crisis Team after an 1 hour assessment and therefore was not under their care and treatment, I having found a failure to obtain all relevant information pertinent to her risk in assessing that risk. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you (and/or 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 July 12, 2024. 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: The family of Lily University of Leicester Girls Day School Trust I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any person who I believe may find it useful or of interest. 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 Dated: 17/05/2024 Miss F BUTLER His Majesty's Assistant Coroner for Leicester City and South Leicestershire Regulation 28 – After Inquest Document Template Updated 16/05/2023
2 responses 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.
NHS) Leicestershire Partnership NHS Trust HE 29 Lloyd Building County Hall Leicester Road Glenfield Leicestershire LE3 8RA www.leicspart.nhs.uk Via email c/o 12! July 2024 Dear Miss Butler Lily Precious Jahany Inquest date: 17" May 2024 On behalf of the Leicestershire Partnership NHS Trust (‘the Trust’), | am responding to your Report to Prevent Future Deaths (hereafter “your Report”) dated 17 May 2024 concerning the death of Miss Jahany. In advance of responding to the concerns raised in your Report, | would like to express my deepest condolences to Miss Jahany’s family and loved ones. The Trust wishes to assure the Jahany family and HM Coroner that the concerns raised about his care have been listened to, reflected upon and action has been taken as a result. In your Report, you raised two Matters of Concern. The first of these Matters of Concern is better addressed by Student Roost who no doubt will respond direct. | will therefore respond to the second matter of concern which is relevant to the Trust. In your report, you have raised a Matters of Concern: 1. | have spent a lot of time in this inquest investigating the information which was known about Lily, about her mental health and who had access to what information in the context of assessing her risk. In September of 2023, Miss Evans, Assistant Coroner sitting within the Rutland and North Leicestershire jurisdiction heard an inquest concerning a student at Loughborough University. Similar to Lily’s case he was under the care of a private psychiatrist elsewhere in the country where he had lived prior to attending university. As a result of concerns in that case (his death occurring 1 year before Lily’) around lack of contact by the Crisis Team at the time of assessment or otherwise with the private psychiatrist, the Coroner wrote to the Leicestershire Partnership Trust to share her concerns. Trust Headquarters: EN Pen Lloyd Building, County Hall, Leicester Road, Glenfield, Leicestershire. LE3 8RA Chair: Chief Executive: The Trust referenced the Crisis Team Standard Operating procedure in the inquest in September 2023, the Coroner was concerned about the level of awareness that staff members had of any expectation required of them set out within that procedure to seek information from other agencies. | now have sight of the Crisis Team Standard Operating Procedure. It sets out the keyworker responsibilities. The section is drafted presupposing that patients are receiving care and treatment from the Crisis Team and only at that point does the responsibility for seeking relevant information from other agencies kick in. Furthermore, the emphasis upon that requirement is limited to one line which reads ‘responsibility for referrals and liaising with other agencies involved’. That is anything but clear as to any expectation upon staff to ensure they have at their disposal all of the relevant risk information at the time of making that assessment; nor does it in my view set out any expectation upon staff to proactively make contact with treating clinicians in the private sector to gain information. It would not capture situations such as Lily's, who was discharged from the Crisis Team after an 1 hour assessment and therefore was not under their care and treatment, | having found a failure to obtain all relevant information pertinent to her risk in assessing that risk. Access to necessary information: We understand and accept the importance of having access to all the necessary information, including previous contact with NHS and private providers during a comprehensive assessment and for safety planning. We have undertaken a full review of the Crisis Resolution Home Treatment Team Standard Operating Procedure and the Mental Health Central Access Point Standard Operating Procedure (SOP). These SOP’s have been updated to explicitly clarify the professional expectations regarding information gathering by liaising with key professionals which includes private providers and psychiatrists. The SOP’s also include a process for what to do when we are unable to contact key professionals including private sector care providers. The Trust continues to be a stakeholder in the Leicester Leicestershire & Rutland (LLR) University workstream, led by the LLR Integrated Care Board. This ensures that collaborative working continues to streamline and optimise access to mental health support and advice for students and university staff across LLR. Thank you for bringing this important patient safety issue to our attention, and I trust that the action we have taken responds to the concern set out by HM Coroner in her Report, with a focus on avoiding a recurrence of the circumstances around Miss Jahany’s death. Yours sincerely Chief Executive Trust Headquarters: EEEEEP en Lloyd Building, County Hall, Leicester Road, Glenfield, Leicestershire. LE3 8RA Chair: «Chief Executive
Charles House 8th Floor 148 Great Charles Street Birmingham B3 3HT 28 June 2024 Response to Regulation 28 Report: After Inquest JAHANY L P 09122022 Dear Miss F Butler, As stated in the Regulation 28 Report for JAHANY L P (09122022) and following its publication, I am writing to you with details of current and proposed future actions which forms our wider suicide prevention strategy at Student Roost. Firstly, I wish to acknowledge that this was a tragic case, and the death of a resident leaves a devastating, lasting impact on our team members. Our thoughts will always be with Ms Jahany’s friends and family. We aim to work collaboratively within the higher education sector, alongside universities throughout the UK, and have seen a dramatic increase in mental health challenges within the student population since the Coronavirus pandemic four years ago. As a result of this, we have significantly invested in resident wellbeing support at Student Roost, creating and growing a team of dedicated resident wellbeing advisors and partnering with Mental Health First Aid England to train over 70 team members as Mental Health First Aiders. This provision is not standard within the Purpose-Built Student Accommodation (PBSA) sector, and we aim to be leaders in driving best practice within the industry. In 2022, we launched our #BehindEveryDoor campaign in partnership with award-winning national mental health charity, Chasing the Stigma. The campaign cements Chasing the Stigma’s award- winning digital app, Hub of Hope, as Student Roost’s official mental health signposting tool for all residents and team members living and working at one of over 50 Student Roost properties in the UK. The QR code, found on posters behind every bedroom door at every property, has seen over 4,500 scans from individuals seeking preventative, tailored support from charities and organisations in their area, and assists us in gaining insight and visibility into student demographics across our properties, allowing us to pinpoint what additional mental health support and guidance residents may require. Quite often, our team members are alerted by a flatmate, friend or relative of the resident in crisis when a serious incident has occurred and then attend to support and assist. They are often not the first to arrive at the scene when there is a resident at risk, or an unfortunate event of a resident death, which is a traumatic experience for all involved. Our teams are trained to enlist the support of the emergency services and university welfare teams where required. There is no expectation on our teams to put themselves in a situation where they don’t feel safe or comfortable. However, after receiving this report, we wholeheartedly believe that providing additional first aid training for our team members, especially to those who feel confident in administering first aid or wish to refresh their existing knowledge, is a step we can take to further ensure the safety and wellbeing of our residents. PBSA Portfolio Advisor Limited t/a Student Roost Registered in England, company number 08721957 Registered office: Charles House, 8th Floor 148 Great Charles Street, Birmingham B3 3HT Charles House 8th Floor 148 Great Charles Street Birmingham B3 3HT As soon as we received this report, our Senior Leadership Team conducted an analysis of our property teams. I’m pleased to share with you that this has resulted in our decision to train 223 operational team members in first aid, with training programmes commencing in August 2024. Following completion of this training, which is estimated to be at the end of this year (2024) all Student Roost properties (over 50 across 21 UK towns and cities) will have access to a trained first aider. We hope you find that our response clearly sets out what actions we are taking following the inquest and publication of your report. Hopefully this also provides you with reassurance that we will continue to implement necessary training, policies and procedures to ensure resident wellbeing and safety will always be our top priority at Student Roost. If you would like further information or have any questions, please do not hesitate to contact me directly. Kind regards, Managing Director – Student Roost PBSA Portfolio Advisor Limited t/a Student Roost Registered in England, company number 08721957 Registered office: Charles House, 8th Floor 148 Great Charles Street, Birmingham B3 3HT
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