Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0691, written 13 Dec 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 13 Dec 2024 |
|---|---|
| Reference | 2024-0691 |
| Deceased | Timothy De Boos |
| Coroner | Nigel Parsley |
| Coroner area | Suffolk |
| Category | Suicide (from 2015) · Mental Health related deaths |
| 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.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Secretary of State Department of Health and Social Care 1. | CORONER | am Nigel Parsley, Senior Coroner, for the coroner area of Suffolk. 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. 3 | INVESTIGATION and INQUEST On 6'" February 2024 | commenced an investigation into the death of Timothy Robert DE BOOS The investigation concluded at the end of the inquest on 5 December 2024. The conclusion of the inquest was that the death was the result of:- The effects of a self-ignited fire at his home address, whilst suffering a relapse of his known psychotic illness. The medical cause of death was confirmed as: 1a Smoke inhalation and severe burns 1b Domestic fire 2 Paranoid schizophrenia, severe right coronary artery atherosclerosis 4 | CIRCUMSTANCES OF THE DEATH Timothy De Boos was declared deceased at his home address in Ipswich, Suffolk on the 6" February 2024. Earlier that day a fire had to be seen coming from the ground floor flat of the address. Tim was seen by a witness to close the window of the flat whilst it was on fire, then disappear from view. Tim made no attempt to leave, and when found was sat or slumped against the door of the room. Timothy was known to the mental health services, and had a prolonged history of being mentally unwell (being diagnosed with paranoid schizophrenia in 2004), with evidence of a previous stated suicidal thought. A subsequent post-mortem examination identified that Tim had died from smoke inhalation and burns. Although clearly able to do so Tim made no effort to leave the burning building, and on a balance of probabilities basis, deliberately remained inside with a view to ending his life Tim had suffered a mental health crisis on the 2" February 2024 and Tim himself, Tim’s family, and Tim’s Mental Health Care Coordinator, all believed he should be admitted to a Mental Health Unit at that time as a voluntary patient. This could not be immediately actioned as a referral to another team was required, and members of that team who subsequently saw Tim the following day, deemed he was no longer in a mental health crisis. If Tim’s admission to hospital had been actioned on the 2" February 2024, he could not have been admitted in any event, as there was already a list of five other individuals waiting to be admitted to the same unit. Had Tim been admitted to a Mental Health Unit on the 2"4 February 2024, his tragic death would not have occurred. CORONER’S CONCERNS During the course of the inquest the evidence revealed matters given 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 as follows. — 1. lam concerned of the continuing lack of Mental Health Unit inpatient beds in Suffolk, and more widely throughout England and Wales. At the time of Tim’s mental health crisis on the 2" February 2024, had the decision to admit him been possible, he still would not have been admitted as there were five other individuals in the queue before him also waiting for admission. The lack of available beds is not a new problem, and | have previously issued two Regulation 28 Prevention of Future Death Reports in which a lack of inpatient Mental Health Unit beds have contributed to a death- Nicola Rayner (died 10" June 2023), reported 7" March 2024. Piotr Kierzkowski (died 17 December 2019), reported 12" October 2020. 2. In Tim’s case, on the 2"¢ of February 2024 Tim’s family, Tim himself, and Tim’s Mental Health Care Coordinator (a Senior Mental Health Nurse who had been supporting Tim for a year), all wished for his admission to a Mental Health Unit as a voluntary patient. It was heard in evidence that a different team (the Crisis Resolution and Home Treatment Team) were the ‘gatekeepers’ for admission and this team could not review Tim until the next day. When reviewed by Crisis Resolution and Home Treatment Team staff (who had never met Tim before), they believed his crisis had subsided and his admission was denied. In evidence Tim’s Mental Health Care Coordinator was adamant that Tim should have been hospitalised on the 2" February, as both his family and Tim himself had also wished. | am therefore concerned that the views of an experienced mental health professional, a patient’s family, and the patient themselves, is deemed insufficient evidence for an admission to a Mental Health Unit as a voluntary inpatient. ACTION SHOULD BE TAKEN In my opinion action should be taken in order to prevent future deaths, and | believe you or your organisation have the power to take any such action you identify. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely 7" February 2025 |, the Senior Coroner, may extend the period if | consider it reasonable to do so. 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;- 1. Timothy’s next of kin. 2. Norfolk and Suffolk Foundation Trust | am under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. She may send a copy of this report to any person who she believes may find it useful or of interest. You may make representations to me, the Senior Coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. 13" December 2024 VE Nigel Parsley
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 26 February 2025 Our Ref: HM Coroner Nigel Parsley Beacon House, Whitehouse Road, Ipswich, IP1 5PB Dear Mr Parsley Thank you for your Regulation 28 report to prevent future deaths dated 13 December 2024 about the death of Timothy Robert De Boos. 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 Timothy’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. The concerns you identified in this case were in respect of the lack of inpatient mental health beds in Suffolk and more widely throughout England and the evidence required for admission to a mental health unit. In preparing this response, my officials have made enquiries with NHS England to ensure we adequately address your concerns. Demand for inpatient services fluctuates across the 24 hour period. The Trust has in place structures and processes to ensure a coordinated and planned approach to ensure the Trust's inpatient bed capacity is optimal. This involves coordination of people who are assessed as requiring admission to hospital and working with partners to ensure timely supported discharges into the community teams. Interventions the Trust have made, alongside partners, are the use of MADE events to support collaborative focussed joint working. In Suffolk these were introduced in May 2024 and occur on a weekly basis. These have been successful coordinating efforts between the Trust, Commissioner and Local Council in helping support discharge for people with complex health needs. In terms of the overall inpatient bed capacity in the Trust is undertaking a benchmarking exercise to review bed utilisation across the organisation in order to optimise the current bed capacity. In addition to this work, the Trust has been working with other organisations who are successful in maintaining low numbers of inappropriate out of area placements. I understand your concerns and I know that the availability of mental health beds is an issue you have raised in previous Prevention of Future Deaths reports and 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. 2025-26 Planning Guidance contains fewer targets across the board to focus on the fundamentals of good care. It instructs systems to reduce the average length of stay in acute mental health beds, and improving patient flow and ensuring appropriate placements are both essential to delivering against this target. Instead of cataloguing all actions the NHS might take, we’re focusing on the things that matter most to patients and giving local leaders the freedom and autonomy they need to provide the best service to their local communities. It is also important that when people are discharged, this happens in a way that considers their needs on discharge and any risks to their safety. To help support safe and timely discharge 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 safe discharge from all mental health and learning disability and autism inpatient settings for children, young people and adults. There has also been learning from the apparent miscommunication between the community and crisis team. The Trust recognise the critical role urgent care pathway plays in supporting both Trust and wider community services. Communication is critical to ensure the correct assessments and pathways of care are provided. The Trust are midway through improvement work to support prompt and clear access to the crisis team for health professionals and internal community teams. This is involving work to maximise availability of staff to receive incoming referrals and enable prompt triage and assessment of needs. In addition, in 2025 the Trust is starting a larger transformation plan of urgent care pathways which includes refinement of the communication methods between teams. The Crisis Team remains the assessors for inpatient services in line with national practice. This is to ensure all opportunities for community interventions are explored because the evidence confirms this generally leads to better recovery outcomes. The community team made the referral to the Crisis Team on 2 February who then completed a visit on 3 and 4 February. The visits assessed that admission to hospital was no longer the immediate care need. I hope this response is helpful. Thank you for bringing these concerns to my attention. Yours sincerely, PARLIAMENTARY UNDER-SECRETARY OF STATE FOR PATIENT SAFETY, WOMEN’S HEALTH AND MENTAL HEALTH
See every Prevention of Future Deaths report matching Suicide (from 2015), and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.