Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2025-0400, written 16 May 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 16 May 2023 |
|---|---|
| Reference | 2025-0400 |
| Deceased | Mark Ravensdale |
| Coroner | Abigail Combes |
| Coroner area | South Yorkshire (West District) |
| Category | Suicide (from 2015) |
| Organisation named | South West Yorkshire Partnership Teaching 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.
ANNEX A REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. South West Yorkshire Partnership NHS Foundation Trust 1 CORONER I am Abigail Combes, assistant coroner, for the coroner area of South Yorkshire (West District) 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 26 April 2022 I commenced an investigation into the death of Mark Ravensdale born on 2 January 1967. The investigation concluded at the end of the inquest on 2 February 2023. The conclusion of the inquest was:- Death by suicide The medical cause of death was: 1a: Hanging 4 CIRCUMSTANCES OF THE DEATH Mark Ravensdale had suffered with mental health conditions for a long period of time. Following one attempt to die by suicide he was placed into a care setting in order to support him before being moved into his own premises. He had a number of difficulties within that setting and continued to suffer with mental health challenges. His GP referred him into mental health services for assessment however when the services made contact with the home he was residing in Mark was not present at the home. The workers spoke to care staff but did not follow up with Mark afterwards and discharged him without speaking to him at any point. Shortly after this Mark was found hanged and his death was by suicide. 5 CORONER’S CONCERNS During the course of the inquest the evidence 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. – 1 There were no attempts by mental health services to speak to Mark directly to properly and adequately assess his mental health condition. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe 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 11 July 2023. 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: and South West Yorkshire Partnership NHS 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 other person who I believe may find it useful or of interest. In this case I have sent a copy of this report to the CQC and South Yorkshire Integrated Care Board. 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. 9 16 May 2023 Abigail Combes 2
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.
12th July 2023 Ms Combes HM Assistant Coroner, South Yorkshire (West) Medico-Legal Centre Watery Street Sheffield S3 7ES Dear Ma’am, Regulation 28 Response – Mark Ravensdale Chief Operating Officer Trust Headquarters Fieldhead Hospital Ouchthorpe Lane Wakefield WF1 3SP Tel: 01924 316298 We write in response to the Regulation 28 report following the inquest touching the death of Mr Mark Ravensdale. We would like to start this response by offering Mr Ravensdale’s family our sincere condolences for their loss. As part of our response, the Trust does not intend to provide any information in respect of the clinical rationales in Mr Ravensdale’s care. We hope the information supplied in this response provides assurance that the Trust has carefully considered the concerns raised and will take appropriate action to address them. There were no attempts by mental health services to speak to Mark directly to properly and adequately assess his mental health condition The Trust’s Single Point of Access (SPA) teams triage approximately 2000 referrals per month. It is therefore essential that all referrals undergo an initial triage by a qualified mental health professional, with the support of the multi-disciplinary team as required, in order to establish an individual’s mental health needs, the most suitable plan for meeting any identified mental health needs and the urgency and priority of any assessment required. In addition to establishing the urgency and nature of the response, the SPA triage process will determine whether a full comprehensive assessment is required. The SPA triage process is aligned with national standards in the form of the UK Mental Health Triage (MHT) Scale Guidelines (Sands, Elsom & Colgate 2015). The triage process would commonly involve direct contact with the person referred unless there are circumstances where it is clinically appropriate to carry out triage using the clinical records, alongside information from professionals and carers working with the individual. This is particularly appropriate when other agencies are directly involved in delivering care and where the person has had recent assessments. Following receipt of the Regulation 28 report the Trust undertook a review of the SPA triage process specific to your concern, led by the Associate Director of Operations, Adults and Older People Mental Health Care Group. It was identified that, although the outcome of any triage process is reached based upon an evidence-based approach in line with the UK Mental Health Triage (MHT) Scale Guidelines and a practitioner’s own clinical assessment, further guidance would support a practitioner to identify when direct contact with the person referred may be clinically indicated. The Trust will therefore develop and implement a triage checklist in respect of the review’s findings. A Plan, Do, Study, Act (PDSA) cycle process will be applied to the implementation of the triage checklist. PDSA cycles provide a model of improvement framework to support change to services and care delivery. PDSA stands for: • Plan – what you are going to do • Do – what you have planned • Study – the results of your actions • Act – on the results and make improvements An initial study of the triage checklist impact upon service and care delivery will be undertaken following 6 months of the checklist’s implementation, with appropriate actions taken as identified by the study. I do hope the above information is of assistance and answers the concerns raised within your Regulation 28 report following the sad death of Mr Mark Ravensdale. Yours sincerely, Chief Operating Officer South West Yorkshire Partnership NHS Foundation Trust
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