Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0598, written 4 Nov 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 4 Nov 2024 |
|---|---|
| Reference | 2024-0598 |
| Deceased | Henry Grierson |
| Coroner | Angela Brocklehurst |
| Coroner area | West Yorkshire Western |
| Category | Suicide (from 2015) · Mental Health related deaths · Child Death (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.
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 1 CORONER I am Angela BROCKLEHURST, 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 30 April 2024 I commenced an investigation into the death of Henry Joseph GRIERSON aged 17. The investigation concluded at the end of the inquest on 31 October 2024. The conclusion of the inquest was that: See Narrative Conclusion. 4 CIRCUMSTANCES OF THE DEATH Henry was as last seen by his parents on the 20th April 24, at 22:15 hours at his home address when he went to bed. He was described as being in good spirits. After his parents had gone to bed, it is believed Henry has left the address in his fathers mother vehicle and is stopped by the Police and the vehicle was seized by Police at 02:15 hours. Following this it is believed Henry has returned home and written in a diary his intention to commit suicide to his family members and has time stamped these in the diary. The time when he started was 0613 hours and finished it at 06:41 hours. It is then believed Henry has taken a length of blue rope from his father's shed and has left the area and walked to a wooded area behind the William Henry school in Rastrick. Henry has then . Henry was found by the a member of the public who was out walking their dog. The emergency services have been contacted and on arrival the Police, have started CPR until the Paramedics arrived who reported life extinct at 10:11 hours. CORONER’S CONCERNS 5 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) On the 13th November 2023 Henry Joseph Grierson with the consent of his Parents discontinued his referral and treatment from the organisation CAMHS, and on the 9th April 2024, Mr Grierson gave notice if his intention to discharge himself from the support organisation Recovery Steps. No evidence has been presented to this Inquest as to the knowledge of these matters by the safeguarding team at Huddersfield New College. Regulation 28 – After Inquest Document Template Updated 30/07/2021 No information concerning the current mental health issues of Mr Grierson had been provided to the College within a mitigation statement provided by him. The evidence before the Court is that the latest communication concerning Mr Grierson's mental health provided by CAMHS was dated October 2023. It is a matter of concern that communication between the college and CAMHS and Recovery Steps was not seemingly maintained to enable an awareness by the College of the current mental health of Mr Grierson in April 2024 and the decisions taken by himself and his family, to remove such external support. 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 30, 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 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: 04/11/2024 Angela BROCKLEHURST HM Assistant Coroner for West Yorkshire Western Coroner Area 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.
23 December 2024 Dear Madam, The College will always do anything we can to support our students, and we welcome the Coroner’s findings. We agree with the Coroner’s conclusion that steps need to be taken to enhance the communication from organisations such as CAMHS to schools and colleges, but consider this to be a conversation that needs to be had at a much higher level. Given that the College does not have the power to make and implement changes on behalf of other organisations, we have met with representatives of the Department for Education to explain the issues and to bring their attention to the challenges regarding multi-agency communication. The provision of clearer guidance about what triggers communication from such organisations would provide valuable clarity for the whole sector. Notwithstanding our view that the discussion around multi-agency co-operation is not completely within our purview, representatives from the College have discussed the issue with their counterparts at the NHS South West Yorkshire Partnership Foundation Trust who have responsibility for CAMHS. In terms of steps that may be taken locally to improve the communication of information we can only act on matters within our control. We understand that the Trust have agreed in principle to write to you to set out the steps they will take as the provider of CAMHS services to address the concern you have raised. In terms of matters that are within our control, the College has reviewed and amended relevant policies and processes for contacting external agencies, particularly where a Welfare Plan has been created or when permanent exclusion is being implemented as a last resort. Included in this review of processes is College staff requesting and expecting updates from the external agencies involved in the safeguarding of a student, as identified and specified in their Welfare Plan. The College’s safeguarding team will remind external agencies of the responsibilities that they have to share safeguarding information, as detailed in ‘Keeping Children Safe in Education’ and ‘Working Together to Safeguard Children 2023’. Since the Coroner’s issuing of the Regulation 28 Report, the College’s safeguarding team have found that information-sharing from external agencies to the College has already improved, specifically external agencies informing us when they have discharged a student under their care. Yours sincerely, Principal Educate | Enrich | Enlighten Telephone: 01484 652341 New Hey Road, Huddersfield, West Yorkshire, HD3 4GL URN: 130539 UKPRN: 10003188
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