Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0548, written 14 Oct 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 14 Oct 2024 |
|---|---|
| Reference | 2024-0548 |
| Deceased | Caroline Staite |
| Coroner | Hugh Bricknell |
| Coroner area | Herefordshire |
| Category | Suicide (from 2015) · Mental Health related deaths |
| Organisation named | Herefordshire and Worcestershire Health and Care NHS Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text recovered by OCR from a scanned PDF. OCR is imperfect: check anything you rely on against the source PDF. Reproduced verbatim, including the scan's own layout.
HG Mark Bricknell Senior Coroner for County of Herefordshire 14th October 2024 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: J Chief Executive, Herefordshire and Worcestershire Health and Care NHS Trust. 1 CORONER 1am Hugh Gregory Mark Bricknell, Senior Coroner for County of Herefordshire 2 CORONER’S LEGAL POWERS | 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. http://www. legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www. legislation.gov.uk/uksi/2013/1629/part/7/made 3 INVESTIGATION and INQUEST On 18 March 2024 I commenced an investigation into the death of Caroline Ann STAITE. The investigation concluded at the end of the inquest on 30 September 2024. The conclusion of the inquest was Suicide. 4 CIRCUMSTANCES OF THE DEATH A member of public on his way home from work, called at 2339 hrs on 8/3/24 stating he was on the Old Bridge Hereford. They described a body with a backpack, dark clothes, and white trainers in the river and stated the river was flowing fast, that the body had now moved into darkness but was heading towards Victoria foot bridge. Officers were deployed to speak with the informant and additional officers were dispatched to numerous locations along the River Wye. A female body was recovered near the Canary Bridge, Hereford and earacicd ANN prot ounces the female deceased at 0241 hours on 9/3/24. The deceased was fully clothed. The deceased had no obvious injuries. contacted the Police saying his sister had not been seen for 24 hours. Her name was Caroline Anne STAITE born 2/6/72. The description matched that of the deceased and subsequent formal identification provided confirmation. 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) The Neighbourhood Mental Health Team should ensure that their procedures are sufficiently robust regarding the sifting of clients for consideration by Mind. (2) The procedure for the return of patients from Mind to the care of the Neighbourhood Mental Health Team should be transparent and encouraged if the Mind worker feels that is appropriate. (3) If so requested by the Mind worker the patient should be returned to the care of the Neighbourhood Mental Health Team and the involvement of the Mind worker discontinued. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you, TM have the power to take such action. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 9 December 2024. |, 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. COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the following Interested Persons CEO Herefordshire Mind. ! am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both ina 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. 14 October 2024 Signature HG Mark Brickyell,/HM Senior Cdroner: Herefordshire
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.
Chief Executives Office 2 Kings Court Charles Hastings Way Worcester WR5 1JR Tel: Email: www.hacw.nhs.uk 9th December 2024 HM Senior Coroner- H G Mark Bricknell HM Coroner’s Office Town Hall St Owen Street Hereford HR1 2PJ Dear Sirs, Re: Regulation 28: Report to Prevent Future Deaths in respect of Ms. Caroline Staite I am writing in response to your report to prevent future deaths dated 14th October 2024 addressed to me, I am grateful for the opportunity of responding to your concerns. The Trust is always keen to learn from any tragic incident and I hope that this response satisfies you that we have reviewed the issues raised appropriately. Following the very sad death of Ms Caroline Staite we identified some areas of learning following our internal patient safety review process which we believe cover the points you have outlined in your Regulation 28 Notice. Whilst we were not called to the Inquest, which may have provided an opportunity for us to expand on the issues identified in our patient safety review, I hope that the information below provides you with confidence that the concern you have identified is being fully addressed. Your concern: Point 1 The Neighbourhood Mental Health teams should ensure that their procedures are sufficiently robust regarding the safely of patients for consideration by MIND. Action: Since this time our Community Service Manager, Diane Topham, who oversees our Neighbourhood Mental Health Team has worked closely with the Herefordshire MIND service to co-produce a Standard Operating Procedure (SOP) for the Community Mental Health Link Worker Service in Herefordshire. I can inform you that the SOP has been implemented in draft form; it is currently going through our organisational ratification process for final sign off. Chief Executive: Chair: We thought that it was important that the SOP clearly outlines the scope of the link worker role as follows: “People receiving a service from the Neighbourhood Mental Health Services can receive support from the Community Mental Health Link worker according to identified need. These include: • People where risk is currently being well managed. • People who have been assessed, do not need the care of the Neighbourhood Mental Health Team but need support to access community services. • People who have been under the care of a support worker and are ready for step-down but still have some social needs. • People ready for step down from the Neighbourhood Mental Health Team but who require community support to enable them to do this.” Your Concern: Points 2 and 3 The process for the return of the patients from MIND to the care of the Neighbourhood Mental Health team should be transparent and encouraged if the MIND worker feels it is appropriate. If so, requested by the MIND worker the patient should be returned to the care of the Neighborhood Mental Health team and the involvement of the MIND worker discontinued. Action: The MIND Link workers now have established links with the Neighbourhood Mental Health teams and daily access to the ‘duty worker’ (registered professional) or Team Manager/ Clinical Lead, where they can identify any areas of concern with care and treatment plans. If the care and treatment plans indicated are beyond the knowledge and skill set of the Link worker (the acuity of the persons symptomology increases or risk increases) the person will be returned to the care of the Neighbourhood Mental Health team. It should be noted that the Link Workers do not need to wait for a planned meeting they can access the support of the Neighbourhood Mental Health team at any point within core working hours should this be clinically indicated. In addition, the Link Workers also have open access to the weekly multi professionals’ meetings in the Neighbourhood Teams should they wish to discuss a case. Conclusion I would like to thank you for drawing this matter to my attention, I confirm that the point you raised has been carefully considered and the response set out above. I confirm that I have no submissions to make about publishing this response. If you have any further queries do not hesitate to contact me. Yours faithfully Chief Executive
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