Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0561, written 18 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 | 18 Oct 2024 |
|---|---|
| Reference | 2024-0561 |
| Deceased | Geoffrey Cheney |
| Coroner | Ian Pears |
| Coroner area | West Yorkshire Western |
| Category | Suicide (from 2015) · Community health care and emergency services related deaths |
| 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: 1 Radis Community Care 1 CORONER I am Ian PEARS, HM Assistant Coroner for the coroner area of West Yorkshire Western Coroner Area 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 22 January 2024 I commenced an investigation into the death of Geoffrey Stuart CHENEY aged 71. The investigation concluded at the end of the inquest on 11 October 2024. The conclusion of the inquest was that: Geoffrey Stuart Cheney hung himself and a short form conclusion of suicide was recorded. 4 CIRCUMSTANCES OF THE DEATH On 8th November 2023 an initial assessment for home treatment was undertaken on Geoffrey Stuart Cheney by the Kirklees Outreach Team. In that assessment Geoffrey indicated that he regularly had suicidal thoughts, including to hang himself. His family asked that be removed. in his flat Geoffrey was admitted as a voluntary patient and after some time was deemed to be fit enough to have unescorted leave. He undertook that successfully on a number of occasions. On 16th January 2024 he went to his home at on unescorted leave. He put the chain on the door and hung himself that was still in place. 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) From the evidence it was clear that there was an assumption that could not be removed and as a result no attempt was made to see if it was actually possible to have removed Regulation 28 – After Inquest Document Template Updated 30/07/2021 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 December 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. COPIES and PUBLICATION 8 I have sent a copy of my report to the Chief Coroner and to the following Interested Persons I have also sent it to Pinnacle Group Limited who may find it useful or of interest. 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: 18/10/2024 Ian PEARS HM Assistant Coroner for West Yorkshire Western Coroner Area Regulation 28 – After Inquest Document Template Updated 30/07/2021
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.
Housing Services, Strategic Manager – Accessible Homes Team
Homes and Neighbourhoods
PO Box 1720
Huddersfield
HD1 9EL
e:
t:
21.11.24.
West Yorkshire Coroners/Radis Community Care
Dear Mr Ian Pears.
RE: Coroners instruction regarding future removal of adaptations.
Kirklees Council write in support of Radis Community Care’s response to the
instruction you have issued to them in connection with the removal of future
adaptations if they present a safeguarding issue.
To give you some additional background with regards to the operational structure,
Radis Community Care is the company who are the care providers to our customers,
Pinnacle Group Ltd and Kirklees Council hold responsibility for all policy aspects of
the property management, including adaptations.
Kirklees Council have a Housing Assistance Policy which lays out how we deliver
adaptations. Previously there was nothing in the policy with regard to removing
adaptations should they present a risk to a person.
Following your report, I can confirm that amendments have been made with immediate
effect to reflect that we may remove adaptations should they pose any risk to any
persons in the household. The Policy is currently undergoing a formal sign-off process
following several amends, but our process for this has already been updated. For
information, the section in the draft Policy reads as follows:
Removing and re-using aids and adaptations.
•
It is standard practice that generally we do not remove minor aids and adaptations
once fitted. If the adaptations are no longer needed it is the responsibility of the
homeowner, landlord or tenant to remove them.
• There are exceptions to this, however, as some aids and adaptations, such as hoists
and stairlifts can be re-used in other properties needing aids and adaptations. Also, we
would consider removing certain adaptations if there are risks to persons or
safeguarding concerns.
• We may re-use some specialist equipment if we have suitable items in stock.
• For Council properties we will endeavour to match an adapted property to the needs
of a person following appropriate assessments from the Accessible Homes Team.
For additional information, on internal review of this case we are not entirely satisfied
that a multi-agency approach was taken, and Kirklees Council will raise a
Safeguarding Adults Review (SAR) referral as soon as possible.
Although we are not sure it will meet the criteria, we believe that a discretionary SAR
will help us identify any learning for future purposes. We believe there are
improvements that can be made in terms of joined up working and improvements on
aligning policies, the SAR process will assist us with this. Specific actions and
timescales will be determined by this process and an update can be shared with the
Coroner’s Office as required.
Should a SAR not be undertaken, Kirklees Council will ensure learning is shared
across all relevant departments and agencies regarding the change to our Policy of
assessing adaptations for risks to persons or safeguarding concerns and the removal
of them where needed.
We are keen to offer support to all agencies involved in this case and if anyone would
like any further discussions, please do not hesitate to contact me.
Yours sincerely
Strategic Manager - Accessible Homes Team
It is standard practice that generally we do not remove minor aids and adaptations once fitted. If the adaptations are no longer needed it is the responsibility of the homeowner, landlord or tenant to remove them. There are exceptions to this, however, as some aids and adaptations, such as hoists and stairlifts can be re-used in other properties needing aids and adaptations. Also, we would consider removing certain adaptations if there are risks to persons or safeguarding concerns.
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