Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0448, written 7 Aug 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 7 Aug 2024 |
|---|---|
| Reference | 2024-0448 |
| Deceased | Martyn Stringer |
| Coroner | Nicholas Graham |
| Coroner area | Oxfordshire |
| Category | 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.
Martyn Stringer
Regulation 28: Prevention of Future Deaths
NOTE: This form is to be used after an inquest.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
NHS England
1
CORONER
I am Nicholas Graham, HM Area Coroner, for the coroner area of Oxfordshire.
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 the 5 April 2023 an Inquest was opened into the death of Martyn Harvey Stringer
who died on the 29 March 2023. On the 25 July 2024 I concluded an Inquest into his
death at the end of a 3-day hearing.
4
CIRCUMSTANCES OF THE DEATH
The immediate circumstances are that: On 24 March 2023, Martyn was
detained by police in Sussex after being found at
ostensibly gone to take his own life. He was taken to Eastbourne District
General Hospital. There he was assessed and deemed liable for detention under
Section 2 of the Mental Health Act. However, there were no available mental
health beds nationally and a suitable placement could not be found for him.
Having been at the hospital since Friday evening, he contacted family members
on Sunday, 26 March who collected him and brought him back to his home in
Oxfordshire.
where he had
On 27 March 2023, Martyn left his home and stepped in front of a lorry on the
A4074. Witnesses described his actions as deliberate. The medical cause of
death was determined following a post-mortem examination to be multi-organ
failure and polytrauma resulting from a road traffic collision
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. –
As you will note from the Conclusion, an application for compulsory detention for Martyn
could not be completed due to the unavailability of beds despite extensive searches
nationally.
My findings were that: ‘It is the case that a Health Based Place of Safety bed did
become available but a decision was taken that due to anticipated demand for
potential patients not to offer this to Martyn.’
And also that: ‘in my view highly likely that Martyn would have benefitted from a
further admission to hospital – as he had previously – and he would have
prevented from further relapse and ultimately taking the actions he did on the
morning of the 27 March.’
I heard evidence from experience mental health professionals that the lack of beds for
those requiring detention under the Mental Health Act was a frequent occurrence.
In my view, you should consider a review of sufficiency of provision for suitable
placements for those requiring compulsory treatment.
6
ACTION SHOULD BE TAKEN
In my opinion, action should be taken to prevent future deaths, and the coroner believes
that your organisations 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 02 October 2024. I, the Area 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 this report to:
• The family of Mr Stringer
• Oxfordshire ICB
• East Sussex ICB
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 other 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.
9
07 August 2024 Mr N Graham
HM Senior Coroner
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.
Mr Nicholas Graham
HM Area Coroner
Oxfordshire Coroner’s Service
The Oxford Register Office
2nd Floor
1 Tidmarsh Lane
Oxford
OX1 1NS
National Medical Director
NHS England
Wellington House
133-155 Waterloo Road
London
SE1 8UG
26/09/2024
Dear Coroner,
Re: Regulation 28 Report to Prevent Future Deaths – Martyn Harvey Stringer
who died on 29 March 2023.
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 7
August 2024 concerning the death of Martyn Harvey Stringer on 29 March 2023. In
advance of responding to the specific concerns raised in your Report, I would like to
express my deep condolences to Martyn’s family and loved ones. NHS England are
keen to assure the family and the Coroner that the concerns raised about Martyn’s
care have been listened to and reflected upon.
Your Report raises concerns over the issue of availability of inpatient mental health
beds.
The number of mental health beds required to support a local population is dependent
on both local mental health need and the effectiveness of the whole local mental health
system, in providing timely access to care and supporting people to stay well in the
community, therefore reducing the likelihood of an admission being necessary.
In some local areas there is a need for more beds. This is being addressed in part
through investment in new units, however, this should be considered as part of a
transformational approach. This is supported by the NHS Long Term Plan (LTP),
which has seen an additional £2.3 billion funding invested in mental health services
from 2019/20 to 2023/24, around £1.3 billion of which is for adult community, crisis
and acute mental health services to help people get quicker access to the care they
need, and to prevent avoidable deterioration and hospital admission. NHS England’s
2024/25 priorities and operational planning guidance reinforces this focus on
improving patient flow as a key priority – with systems directed to reduce the average
length of stay in adult acute mental health wards, in order to deliver more timely access
to local beds.
To address the wider system issues that impact on health services, a further £1.6
billion has been made available via the Better Care Fund from 2023-2025. This funding
can be used to support mental health inpatient services as well as the wider system,
which should help to reduce pressures on local inpatient services so that those who
need to access beds can do so quickly and locally.
This is being supplemented by a further £42 million recurrent investment from 2024/25
for all Integrated Care Boards (ICBs) in the country, to recommission inpatient care in
line with local models that provide the best evidence of therapeutic support.
NHS England’s South East region have also established a Quality Transformation
Programme relating to Urgent and Emergency Care and Flow. The aim of this
programme is to improve access and quality of the mental health crisis and acute adult
pathway, including improving patient flow and capacity. The region is engaged with
the national Quality Transformation Programme designed to help systems transform
their current service offer. The national programme is built upon the cornerstones of
good mental healthcare, continuity of care, therapeutic relationships and a relentless
commitment to mental health care, meeting the needs of all people.
I would also like to provide further assurances on the national NHS England work
taking place around the Reports to Prevent Future Deaths. All reports received are
discussed by the Regulation 28 Working Group, comprising Regional Medical
Directors, and other clinical and quality colleagues from across the regions. This
ensures that key learnings and insights around events, such as the sad death of
Martyn, are shared across the NHS at both a national and regional level and helps us
to pay close attention to any emerging trends that may require further review and
action.
Thank you for bringing these important patient safety issues to my attention and please
do not hesitate to contact me should you need any further information.
Yours sincerely,
National Medical Director
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