Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0588, written 28 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 | 28 Oct 2024 |
|---|---|
| Reference | 2024-0588 |
| Deceased | Malcolm Taylor |
| Coroner | Jacqueline Lake |
| Coroner area | Norfolk |
| Category | Suicide (from 2015) · Mental Health related deaths · Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Norfolk and Suffolk NHS Foundation Trust |
| 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 NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: The Secretary of State for Health and Social Care: The Department of Health and Social Care Email: 1 CORONER I am Jacqueline LAKE, Senior Coroner for the coroner area of Norfolk 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 12 March 2024 I commenced an investigation into the death of Malcolm John TAYLOR aged 76. The investigation concluded at the end of the inquest on 25 October 2024. The medical cause of death was: 1a) 1b) 1c) 2) Drowning Ischemic Heart Disease, Cardiomegaly, Liver Fibrosis The conclusion of the inquest was: Suicide while suffering from extreme distress 4 CIRCUMSTANCES OF THE DEATH Mr Taylor was referred to Adult Social Services and Mental Health Team in December 2023. He was low in mood following the death of his wife. From February 2024 Mr Taylor's mood worsened and he remained under the care of the Mental Health Team. He was not taking his medication and had psychotic episodes and following assessment it was agreed consideration should be given to his being admitted to a mental health hospital. Mr Taylor expressed thoughts of self harm and suicidal intent. It was deemed appropriate not to carry out a formal Mental Act Assessment until a bed was available due to his paranoid presentation around professionals and concern his risk of self harm would increase. There was an urgent request for a bed to be found in a mental health hospital. On 3 March 2024 . He probably entered Mr Taylor drove to Gorleston the sea at some time between 22.21 and 8 minutes after midnight on 4 March 2024. Mr Taylor was found on the shoreline at Gorleston beach on 4 March 2024. Mr Taylor died from drowning. A bed in a mental health hospital had not been found prior to Mr Taylor's death. Regulation 28 – After Inquest Document Template Updated 30/07/2021 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. Evidence was heard from NSFT as to action they have taken in an attempt to increase the number of beds available and so prevent future deaths, such as daily meetings of senior staff to discuss caseloads identified at high risk, prioritising those at high risk, weekly meetings with Directors and multi agencies to consider patient flow through the system and discussion with partner organisations to remove barriers to discharge to improve patient flow especially those with social care requirements. Despite these steps there remain insufficient beds available to meet patient need. At the time of Mr Taylor's death there were 13 patients awaiting beds. At the time of inquest, there were 7 patients awaiting beds. There are peaks and lows with these numbers on a daily basis but overall there remains a shortage of beds. 2. Evidence was heard this is a national problem and not limited to Norfolk and Suffolk NHS Trust. 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 23, 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 - son Norfolk and Suffolk Foundation 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. Regulation 28 – After Inquest Document Template Updated 30/07/2021 9 Dated: 28/10/2024 Jacqueline LAKE Senior Coroner for Norfolk County Hall Martineau Lane Norwich NR1 2DH Regulation 28 – After Inquest Document Template Updated 30/07/2021
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.
Parliamentary Under Secretary of State for Patient Safety, Women’s Health and Mental Health 39 Victoria Street London SW1H 0EU 020 7210 4850 08 January 2025 Our Ref: Jacqueline Lake Senior Coroner County Hall Norwich NR1 2UA Dear Mrs Lake, Thank you for your Regulation 28 report to prevent future deaths dated 28 October 2024 about the death of Malcolm John Taylor. I am replying as the Minister with responsibility for mental health and patient safety. Firstly, I would like to say how saddened I was to read of the circumstances of Malcolm’s death and I offer my sincere condolences to his family and loved ones. The circumstances your report describes are concerning and I am grateful to you for bringing these matters to my attention. I understand your concerns about insufficient mental health beds being available both locally and nationally to meet patients’ needs. I am sure you will appreciate that the number of mental health inpatient 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 inpatient admission being necessary. I expect individual trusts and local health systems to effectively assess and manage bed capacity and the ‘flow’ of patients being discharged or moving to another setting. I recognise that mental health services have been under significant pressure in recent years due to the rise in demand and the Department will continue to work with the NHS to address capacity across the system. Over the past few years, the NHS has been developing the community mental health framework to improve community support for people with severe mental illness, thus avoiding the need for an inpatient admission where possible and freeing up more beds. NHS England’s 2024/25 priorities and operational planning guidance reinforces this focus on improving patient flow as a key priority – with local health systems directed to reduce the average length of stay in adult acute mental health wards to deliver 1 more timely access to local beds. And in areas where there is a clear need for more beds, this has been addressed in part through investment in new units, as part of a this whole system transformation approach. To help support such decisions, the Department published statutory guidance on Discharge from mental health inpatient settings in January 2024 and which is available at: Discharge from mental health inpatient settings - GOV.UK (www.gov.uk). This sets out how health and care systems should work together to support discharge from all mental health and learning disability and autism inpatient settings for children, young people and adults. As part of our mission to build an NHS fit for the future, we will make sure more mental health care is delivered in the community, close to people’s homes, through new models of care and support, so that fewer people need to go into hospital and that beds are available for when people need higher levels of support. I hope this response is helpful. Thank you for bringing these concerns to my attention. Yours sincerely,
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