Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0454, written 5 Sep 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 5 Sep 2025 |
|---|---|
| Reference | 2025-0454 |
| Deceased | James Cochrane |
| Coroner | Rebecca Connell |
| Coroner area | Rutland and North Leicestershire |
| Category | Suicide (from 2015) · Mental Health related deaths |
| Organisation named | Leicestershire Partnership NHS 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 Leicestershire Partnership NHS Trust 1 CORONER I am Rebecca CONNELL, His Majesty's Assistant Coroner for the coroner area of Rutland and North Leicestershire. 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 27 November 2023 I commenced an investigation into the death of James Ralph COCHRANE aged 36. The investigation concluded at the end of the inquest on 27 August 2025. The conclusion of the inquest was that: Mr James Ralph Cochrane died on 17 November 2023 when he jumped from the overbridge, into the carriage way. He was struck by a passing vehicle and sustained catastrophic head, chest and pelvic injuries which resulted in his death. James had schizoaffective disorder which lead to fluctuations in his mood and level of psychosis. It is unclear as to whether he was having a depressive or psychotic episode at the time of the incident and therefore it is not possible to say whether James intended the consequence of the act. The cause of death was established as: I a Catastrophic head, chest and pelvic injuries I b I c II Schizoaffective disorder 4 CIRCUMSTANCES OF THE DEATH Mr James Cochrane was diagnosed with Schizophrenia in 2012 following an admission to the Bradgate Mental Health Unit. His diagnosis was later changed to Schizoaffective disorder due to his the symptoms of psychosis and mood change that he was experiencing which fluctuated over short periods. James was initially under the care of the Psychosis and Early Intervention Recovery (PIER) Team Regulation 28 – After Inquest Document Template Updated 16/05/2023 before being transferred to the care of Charwood Community Mental Health Team (CCMHT) which continued until James passed away. During this period James also had three short episodes of care from the Crisis Resolution and Home Treatment Team (CRHTT), the latter being from 25 October 2023 – 7 November 2023. In October 2022 James medication was changed from Olanzapine to Ariprazole. James' GP reported that following the change in James medication he became less sleepy but he in fact became hyperactive and psychotic to a certain extent, and although James lost a lot of weight his mental health issue resurfaced. James family shared with the CPN concerns that the change in medication was having a negative impact on his mental health. James Community psychiatric nurse felt that the negative effects of the change in his medication were outweighed by the fact that he was more active. These concerns were not shared with his consultant psychiatrist in the community. On 25 October 2023 James went to see his GP stating that he was considering self-harm and wanted to jump off a motorway bridge. James was referred to the mental health Central Access Point (CAP), following which he was referred to the CRHTT. James was seen by the CRHTT on seven occasions during which it was reported that although his suicidal thoughts remained they had decreased. James' Community Psychiatric Nurse (CPN) indicated by email that it would be preferable for the CRHTT involvement with James to be reduced, due to a risk of over reliance on services. However, evidence was heard that from the CRHTT that their input was appropriate at that time. James was discharged from the CRHTT on 7 October 2023. His CPN declined a joint visit and advised that would not have advised James to CRHTT originally, as it made things difficult to have lots of difficult perspectives. On the morning of Friday 17 November 2023, James' mother called CCMHT as about James as he was presenting with psychotic symptoms. had concerns As James had expressed a wish to alter his CPN, the team lead returned Mrs Cochrane's call, rather than his usual CPN. James' mother told the team lead that James was the worst he had been since his admission to the Bradgate Mental Health Unit 12 years earlier, which is when he previously self harmed, that he had lost insight and was walking around in circles thinking he was god. The team lead considered it appropriate to review James in person. Prior to the visit she reviewed James risk assessment and his recent discharge letter from the CRHTT which referenced the fact that James had been referred to them having reported that he had planned to jump off a bridge and had written a suicide note. She also spoke to the CPN who advised that James had not been a risk to himself for 12 years, and that James' beliefs that he was God were nature. in chronic On arrival at James' home at approximately 3.30pm, the team lead initially spoke to James in the absence of his parents. She assessed James as having insight into his mental health. James brother showed her a video of James that had been taken at 1.21pm in which James was saying that he was god. We have heard evidence that James was potentially in psychosis and lacked capacity at the time of the video. The team lead only watched the first 19 seconds of the video which lasted 3 minutes and 27 seconds. felt uncomfortable, as James appeared did not watch the video in its entirety as uncomfortable and sought James consent. Having spoken to James, the team lead asked James' parents what had changed since the time of the video and they confirmed that they had managed to talk James round. didn’t have his consent to watch it, albeit does not believe that Regulation 28 – After Inquest Document Template Updated 16/05/2023 They said that the episodes come and go and appear to build to a peak. believed that James presentation The team lead said that didn’t understand James baseline. was longstanding, and initially considered that the video may have been staged. However did not check further with James' usual CPN how this presentation compared to his baseline. Following the meeting the Team lead prescribed additional medication, namely Zopiclone, to assist James with sleeping and to reduce agitation levels for collection the next day, and advised that he increase his Quetiapine to . A follow up review was arranged with the CMHT consultant psychiatrist. James' parents were advised to contact the CCMHT on Monday if there was improvement. no Lorazepam, James went to bed and at approximately 2100 he left home on foot and went to the overbridge. Having realised that James has left the house, his brother followed him. James overbridge where he jumped into the oncoming traffic and made his way to the sadly James subsequently died as a result of the injuries that he sustained 5 CORONER’S CONCERNS During the course of the investigation my inquiries revealed matters giving rise to concern. In my In the circumstances it is opinion there is a risk that future deaths could occur unless action is taken. my statutory duty to report to you. The MATTERS OF CONCERN are as follows: (brief summary of matters of concern) I indicated at the conclusion of the inquest that would be making a prevention of future death report in relation to the following three areas: The extent to which additional evidence such as video footage and carers views should be taken into account. I heard evidence that work and training has been done to encourage staff to listen to careers views. However, it remains unclear as to whether any views obtained are subsequently used to inform any follow up safety plan made by the health care professionals. The extent to which staff should consider evidence provided in alternative formats such as video evidence. It was acknowledged during the inquest that recordings from mobile phones can provide helpful evidence of a patients presentation. I understood that a question had been raised internally at the trust as to what extent such evidence should be viewed, and used to inform decisions, however a final decision has not been made. Given the use of mobile phones etc in modern society, I am concerned that there is no clear guidance to staff as to how such evidence should be used. Support offered to carers who are providing support to mental health patients. It was acknowledged that carers have an important role. I heard evidence regarding mechanisms that have been put in place via systmone to record carers views, but it is unclear as to what checks are in place to ensure that carers are equipped to support patients in their home environment. 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 October 31, 2025. I, the coroner, may extend the period. Regulation 28 – After Inquest Document Template Updated 16/05/2023 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 Leicestershire Partnership NHS Trust 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: 05/09/2025 Rebecca CONNELL His Majesty's Assistant Coroner for Rutland and North Leicestershire Regulation 28 – After Inquest Document Template Updated 16/05/2023
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.
Room 100/110 Pen Lloyd Building County Hall Leicester Road Glenfield Leicestershire LE3 8RA Assistant Coroner Ms Connell 30th October 2025 Dear Assistant Coroner Ms Connell, Regulation 28 Report following an inquest into the death of Mr James Ralph Cochrane I am writing following receipt of the Regulation 28 Report dated 5 September 2025, relating to the inquest into the death of James Cochrane which concluded on 27 August 2025. I would like to express my deepest condolences to Mr Cochrane’s family and friends. Leicestershire Partnership NHS Trust (the Trust) takes these matters very seriously and wishes to assure the Cochrane family and the HM Coroner that the concerns raised about the care Mr Cochrane received have been listened to, reflected upon and action has been taken as a result. In your Regulation 28 Report to prevent future deaths, you set out a number of areas of concern and I would like to detail the changes and improvements made in each of those areas, appending evidence where I believe it is helpful. Concern 1: The extent to which additional evidence such as video footage and carers views should be taken into account. I heard evidence that work, and training has been done to encourage staff to listen to carers views. However, it remains unclear as to whether any views obtained are subsequently used to inform any follow up safety plan made by the health care professionals. Response: The Trust acknowledges the importance of listening and capturing carers views during assessment and routine follow ups and therefore has ensured that these views can be documented (with consent Trust Headquarters: Room 100/110 Pen Lloyd Building, County Hall, Leicester Road, Glenfield, Leicestershire. LE3 8RA Chair: Crishni Waring Chief Executive: Angela Hillery from the patient) in the care and safety planning processes within Community Mental Health (CMH) services. Attached at Appendix 1 is a nursing intervention care plan and in Appendix 2, there is a collaborative care plan; these documents can be accessed and are held within the electronic patient record (SystmOne) and they have sections throughout the plans where carers views can be captured on the difficulties the patient is facing, the patient’s wellbeing and needs, the patients physical, social inclusion and spiritual needs. These forms are accessible to all clinicians and services whenever they access the patient’s electronic records to ensure continuity of care wherever the patient may present. This information is also ultimately used to inform the patients care and treatment plans and decisions during multi-disciplinary and multi professional team meetings and discussions. In addition, Leicestershire Partnership NHS Trust is rolling out the nationally recognised Carers Trust Triangle of Care (TOC) framework and currently community mental health teams are completing self-assessments (due 31 October 2025), which include benchmarking current practice and identifying any actions needed to include carers throughout a patient’s journey of care. The Trust also follows the Culture of Care programme and implements guidance embedding the 12 Culture of Care standards. These commitments are interlinked and fundamental to carers’ involvement as an integral aspect of patient care. The Trust has also embedded the Patient and Carer Race Equality Framework (PCREF) that supports our services with the delivery of high standards of care via simple and effective patient and carer feedback mechanisms and that ultimately minimises racial inequalities. In August 2025, Leicester City service Age UK joined us to share information and support for carers in the city and in June 2025, Voluntary Action South Leicestershire (a County carer commissioned service) did the same. The Trust further invited MOSAIC, who are another local voluntary community sector service offering support to carers across the system and they have picked up a lot of the services from the carers centre closure in January 2025. Monthly newsletters from these services are also shared with the Trust’s Triangle of Care Leads and cascaded to teams and services. Concern 2: The extent to which staff should consider evidence provided in alternative formats such as video evidence. It was acknowledged during the inquest that recordings from mobile phones can provide helpful evidence of a patients’ presentation. I understood that a question had been raised internally at the Trust as to what extent such evidence should be viewed, and used to inform decisions, however a final decision has not been made. Given the use of mobile phones etc in Trust Headquarters: Room 100/110 Pen Lloyd Building, County Hall, Leicester Road, Glenfield, Leicestershire. LE3 8RA Chair: Crishni Waring Chief Executive: Angela Hillery modern society, I am concerned that there is no clear guidance to staff as to how such evidence should be used. Response: The Trust acknowledges the importance of safely maximising technological resources to improve the care and support we provide to our patients (and their families / carers) wherever they may present, to ultimately enhance patient safety and improve overall outcomes for all. In September, our Data Privacy Team created a One Minute Brief on Data Privacy – Viewing videos of patients taken by family members, carers, or friends (Appendix 3) which provides advice and guidance to support our clinical staff who see patients in the community. This will be shared locally with all mental health teams by the end of November 2025 and was shared in trust-wide communication on 26 September 2025 (Appendix 4). Also, the Trust’s Electronic Health Records Policy (including Record Keeping Management) will be updated to reflect the One Minute Brief on Data Privacy – Viewing videos of patients taken by family members, carers or friends will be updated by the end of November 2025. Concern 3: Support offered to carers who are providing support to mental health patients. It was acknowledged that carers have an important role. I heard evidence regarding mechanisms that have been put in place via SystmOne to record carers views, but it is unclear as to what checks are in place to ensure that carers are equipped to support patients in their home environment. Response: We acknowledge the important (and sometimes challenging) role that carers have when supporting patients in their home environment. When staff attend patients in the community, the Trust advises staff to ask carers if they require support mechanisms they have in place in light of their own role as carer. This is reflected in the nursing intervention plan (Appendix 1) and the collaborative care plan (Appendix 2) to ensure documentation of the carer’s views and responses. We hold the view that where a carer identifies the need for additional support to look after their loved ones and in particular, due to the presenting circumstances of the patient, the Trust would refer the carer to social care for a carer’s assessment. The Trust further offers a variety of support to carers via signposting to a range of local statutory and voluntary services: For instance, when patients are accepted onto the community mental health services’ caseload, a Welcome Pack (Appendix 5) which includes signposting for carers and Mental Health and Wellbeing Trust Headquarters: Room 100/110 Pen Lloyd Building, County Hall, Leicester Road, Glenfield, Leicestershire. LE3 8RA Chair: Crishni Waring Chief Executive: Angela Hillery Support Booklet (Appendix 6), which includes references to the Joy app and support for carers, is sent to the patient via post or email on assessment. Also, a Carers pack (Appendix 7) is available on the Trust’s website, and an individual identified as caring for someone (whether that’s an official carer or someone who wouldn’t declare themselves a carer but has caring responsibilities) is given a carer’s pack (regardless of whether the patient is accepted onto the caseload). Furthermore, in the autumn 2025 term, a course for carers is being launched through the Leicestershire Recovery College as an additional offer to carers. I trust that the proposed actions that we have described above do, collectively, provide assurance that the Trust is taking a number of immediate measures to respond to the concerns set out by HM Coroner in her Report, with a focus on avoiding a recurrence of the circumstances around Mr Cochrane’s death. Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information. Yours sincerely Chief Executive Trust Headquarters: Room 100/110 Pen Lloyd Building, County Hall, Leicester Road, Glenfield, Leicestershire. LE3 8RA Chair: Crishni Waring Chief Executive: Angela Hillery
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