Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0018, written 10 Jan 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 10 Jan 2025 |
|---|---|
| Reference | 2025-0018 |
| Deceased | Jan Raciborski |
| Coroner | Robert Simpson |
| Coroner area | Berkshire |
| Category | Suicide (from 2015) · Mental Health related deaths |
| Organisation named | Oxford Health 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: 1 CEO, Oxford Health NHS Foundation Trust 1 CORONER I am Robert SIMPSON, Assistant Coroner for the coroner area of Berkshire 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 09 February 2024 I commenced an investigation into the death of Jan Michael RACIBORSKI aged 62. The investigation concluded at the end of the inquest on 10 January 2025. The conclusion of the inquest was that: On the 5th February 2024 Jan Michael Raciborski died at his home address in Caversham after he hung himself. He had suffered with mental health issues for the majority of his life which, along with the impact of a brain injury resulting from an historic attempt to end his life, significantly affected his mood and decision making processes. 4 CIRCUMSTANCES OF THE DEATH Mr Raciborski suffered from depression and a brain injury for many years. This led to a complex presentation and he was under the care and treatment of the South Oxon Adult Mental Health Team (AMHT) from 2022. He had previously been sectioned, spent time as a voluntary patient and the mental health services had had involvement on and off over the past 40 years. The AMHT worked closely with Mr Raciborski and he had both a care co-ordinator and support worker, as well as involvement with further staff members. He had many contacts with them during his final period of care. He had a history of impulsive actions and intermittent suicidal thoughts. In August 2023 his condition deteriorated before then improving. In November 2023 this happened again and this presentation was in keeping with a pattern over the years. In January 2024 he had a fleeting thought of suicide and was assessed by a mental health team in London. He subsequently had contact with his local AMHT. He remained distressed over the following days until he was found deceased on the 5th February 2024. 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) Regulation 28 – After Inquest Document Template Updated 30/07/2021 None of the records of contact with Mr Raciborski completed by the AMHT in the period from August 2023 to the date of Mr Raciborski’s death contained any written record of a risk assesment. I found that in Mr Raciborski’s case this absence did not impact his treatment and was not a causative factor. However my concern is that the failure to properly record the details of a risk assesment can lead to inadequate information sharing and the possiblity of someone who relies upon the records gaining the wrong impression. In addition it does not allow the adequacy of the risk assesments to be properly investigated and could hinder investigations into deaths; which mean that a matter giving rise to a risk to life may not be identified in future investigations. 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 March 07, 2025. 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 Mr Raciborski’s family. 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: 10/01/2025 Robert SIMPSON Assistant Coroner for Berkshire Regulation 28 – After Inquest Document Template Updated 30/07/2021 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.
Private & Confidential Mr R Simpson Assistant Coroner for Berkshire Sent via email to - Dear Mr Simpson, Chief Executive’s Office Trust Headquarters Littlemore Mental Health Centre Sandford Road Littlemore Oxford OX4 4XN 3 March 2025 Regulation 28 report – Jan Raciborski Inquest concluded on 10 January 2025 Response of Oxford Health NHS Foundation Trust Thank you for your report dated 13 January 2025 following the conclusion of the inquest into the very sad death of Jan Raciborski on 5 February 2024. You have stated these concerns to me – None of the records of contact with Mr Raciborski completed by the AMHT in the period from August 2023 to the date of Mr Raciborski’s death contained any written record of a risk assessment. I found that in Mr Raciborski’s case this absence did not impact his treatment and was not a causative factor. However my concern is that the failure to properly record the details of a risk assessment can lead to inadequate information sharing and the possiblity of someone who relies upon the records gaining the wrong impression. In addition it does not allow the adequacy of the risk assessments to be properly investigated and could hinder investigations into deaths; which mean that a matter giving rise to a risk to life may not be identified in future investigations. Your report has been shared with senior colleagues at the Trust including the Chief Medical Officer, the Chief Nurse and the Clinical Director, the Service Director and the Associate Director of Nursing for Oxfordshire Mental Health. It has also been shared with our Patient Safety team, one of whose members attended the first day of the inquest in order to hear the evidence and your examination of evidence first-hand. The team manager of the South Oxon Adult Mental Health Team also attended court on the first day of Mr Raciborski’s inquest and has subsequently listened to the audio recording of your summing up and findings of fact on the second day. The team manager’s attendance at the inquest in order to listen to the evidence provided further valuable insight into the contacts that the AMHT had with Mr Raciborski. Following the conclusion of the inquest, the team manager has taken local actions in relation to your concerns including (a) all supervisors in 1 the Wallingford, Henley and Thame service are attending supervision training to refresh skills and she has asked that this is extended to all of the teams in South Oxfordshire and (b) a meeting in relation to CPA discharge discussions, within which the team discussed risk and how to document assessments of risk. The team manager will also complete spot checks of clinical notes with a focus on the concerns that you identified. More broadly across the Trust, we know that maintaining good quality and effective written records is a core requirement of clinical practice. Staff receive training to help them to do so and their clinical record keeping is reviewed and discussed in supervision sessions. The focus is to reduce the reliance on one word risk assessment summaries, and move towards increased therapeutic engagement with safety planning, which has greater evidence to reduce poor outcomes. The Trust Core Clinical Standards in Mental Health and Learning Disability Care Policy gives colleagues guidance and direction as to the requirements and recording of risk assessment and information for both inpatient and community settings. We developed a clinical audit tool in the autumn of 2024 in order to check patient records against the policy and the standards to which we aspire. The tool reviews the following areas relating to the recording of risk information: A qualitative review of the quality and completeness of the risk assessment The timeliness of the review dates of the risk assessment A qualitative review of the quality and completeness of the risk management plan A review of the involvement of patients, relatives and staff in the development of the risk management plan The timeliness of the review dates of the risk management plan Assessment of the risk of suicide or self-harm and where indicated completion of a safety plan to respond to the identified risks The Trust’s Clinical Risk Assessment and Management (CRAM) Policy sets out the standards for assessment, formulation and recording of risk assessment. The policy was most recently updated in February 2023 and is due for next review in February 2026. I have asked the CRAM policy owner to consider if an earlier review is required, given your concerns. I hope that this provides you with assurance as to the steps that the Trust is taking following the conclusion of the inquest and your concerns. Please do not hesitate to contact me if I can assist any further. Yours sincerely, Chief Executive 2
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