Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0471, written 16 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 | 16 Sep 2025 |
|---|---|
| Reference | 2025-0471 |
| Deceased | Christian Marsh Prevention of future deaths report |
| Coroner | Leila Benyounes |
| Coroner area | West Yorkshire (East) |
| Category | Suicide (from 2015) |
| Organisation named | Leeds and York Partnership 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 THIS REPORT IS BEING SENT TO: 1. Leeds and Yorkshire Partnership Foundation Trust (Intensive Supportive Service) 2. Leeds Survivor-Led Crisis Service (Leeds OASIS) 1 CORONER 1 am Leila Benyounes, Assistant Coroner for the coronial area of West Yorkshire (Eastern). 2 CORONER'S LEGAL POWERS 1 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.. http://www.legislation.gov.Uk/ukpga/2009/25/schedule/5/paragraph/7 http://www.legislation.gov.Uk/uksi/2013/1629/part/7/made 3 INVESTIGATION and INQUEST On 31 January 2025 an investigation was commenced into the death of Christian Barry Marsh. The investigation concluded at the inquest on 16 September 2025. The conclusion of the inquest was: Suicide The medical cause of death was: la) Hanging 4 CIRCUMSTANCES OF THE DEATH The Deceased, who had a past medical history which included excess alcohol use and recent alcohol withdrawal, was found hanging in a bathroom on 6 January 2025 at the respite facility where had been staying since 3 January 2025 and was pronounced dead at the scene. The Deceased had developed physical and mental health symptoms from alcohol withdrawal and had suffered a worsening of his mental health symptoms in December, which resulted in a psychiatric assessment at hospital and a referral for intensive home based treatment. 1 Following an impulsive overdose of on 26 December 2024, the Deceased was admitted to hospital on 28 December 2024 and underwent a further psychiatric assessment and was discharged to a respite facility on 3 January 2025, as an alternative to continued hospital admission, under the care of the intensive support service. The Deceased received a visit from the intensive support service on 4 January 2025 and concerns about the Deceased's confusion were raised with the clinical team by staff at the respite facility. No visit took place on 5 January 2025 due to adverse weather conditions, which meant that the 48 hour review did not take place. There is no recorded documentation of any communication between the clinical team and the staff at the respite facility as to the Deceased's presentation or level of risk on 5 and 6 January 2025, and no plan for the 48 hour review to take place on an alternative date. No pre-death communications were discovered, but 1 am satisfied that the Deceased applied a ligature, with the intention of ending his life. Death was certified at 12.04 on 6 January 2025 in Leeds. 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: There remains no system for formal communication, sharing and handover of information about patients who are admitted to the respite facility operated by Leeds Survivor-Led Crisis Service, but remain under the clinical care of the Intensive Support Service at Leeds and Yorkshire Partnership Foundation Trust. It was candidly accepted in evidence that there needs to be an improvement in communication channels and information sharing for the partnership to run efficiently and effectively and to mitigate risk. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and 1 believe you have the power to take such action. 7 YOUR RESPONSE 2 You are under a duty to respond to this report within 56 days of the date of this report, by 11 November 2025. 1, 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 1 have sent a copy of my report to the Chief Coroner and to the following Interested Persons: the Family of the Deceased. 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 coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. 9 LEILA BENYOUNES Assistant Coroner for West Yorkshire (Eastern) 16 September 2025 3
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.
Date: 07th November 2025
Ms Leila Benyounes
Assistant Coroner for West Yorkshire
(Eastern)
His Majestys Coroners Office
The Coroners Courts
Burgage Square
WAKEFIELD
WF1 2TS
Dear Ms Benyounes
Leeds and York Partnership NHS Foundation Trust
2150 Century Way
Thorpe Park
Leeds
LS15 8ZB
Leeds Survivor-Led Crisis Service
Dial House
12 Chapel Street
Halton
Leeds
LS15 7RW
RE: REGULATION 28 REPORT TO PREVENT FUTURE DEATHS: Christian Barry Marsh,
(Deceased)
Thank you for the correspondence regarding the outcome of the inquest touching upon the
death of Mr Christian Barry Marsh. We would firstly like to take this opportunity to express
our sincere condolences to Christian’s family and friends at the tragic death of Christian.
Following the Regulation 28 Report to Prevent Future Deaths issued on the 16th of
September 2025 to Leeds and York Partnership NHS Foundation Trust (LYPFT) and Leeds
Survivor-Led Crisis Service (Leeds Oasis), please find below the details of our joint response
to address the concerns raised.
The Matter of Concern within the Regulation 28 report are below in bold text with our
response following:
There remains no system for formal communication, sharing and handover of
information about patients who are admitted to the respite facility operated by Leeds
Survivor-Led Crisis Service, but remain under the clinical care of the Intensive Support
Service at Leeds and York Partnership NHS Foundation Trust. It was candidly
accepted in evidence that there needs to be an improvement in communication
channels and information sharing for the partnership to run efficiently and effectively
and to mitigate risk.
1. Standardised Daily Handover and implementation of daily ‘huddle’ meeting
• A standardised daily handover template has been developed to ensure key
clinical information is captured in a standardised format. The handover
document is completed daily for all patients by the Oasis team and includes
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demographic information. It also records whether the person is a guest,
meaning they are using overnight accommodation or a visitor, who attends
during the day only. Additional fields include whether a 48-hour review is
required, any LYPFT tasks that need to be actioned, incidents that have
occurred in the past 24 hours, comments for the multi-disciplinary team (MDT),
and whether a call back or joint review is needed.
Once completed, the handover sheet is emailed to the appropriate LYPFT
Crisis Resolution Intensive Support Service (CRISS) team. There are three
locality teams East, South, and West, and the handover is sent to the
corresponding area in which the individual is currently receiving care. The shift
coordinator within the CRISS team is responsible for accessing this information
and ensuring this is taken for discussion in the daily ‘huddle’ meeting as
described below.
• A daily ‘huddle’ has been established to provide dedicated time for the Oasis
staff and registered staff member from CRISS team to come together and
discuss the information contained within the handover document. This meeting
is held via Microsoft Teams and takes place prior to the daily LYPFT Multi-
Disciplinary Team (MDT) meetings, enabling immediate actions and queries to
be addressed.
Through implementing this process, it has ensured timely and accurate
information sharing between the two services, supporting continuity of care and
effective clinical decision-making.
2. Multidisciplinary Review Meetings
• An MDT meeting (Multi-Disciplinary Team meeting) is a structured gathering of
professionals from various disciplines who collaborate to discuss and plan care
for individuals. These meetings are essential for ensuring holistic, coordinated,
and person-centred care. LYPFT MDT meetings are held daily in each locality:
East, South & West, and are attended by LYPFT staff including and not
restricted to Consultant Psychiatrist, Psychologists, Mental Health Nurses,
Occupational Therapists and Support Workers.
• To strengthen the sharing of information between the two services, the shift
coordinator within CRISS is now responsible for ensuring the handover
information from Oasis is brought into the MDT.
3. Documentation improvements
• Oasis records the handover details and any required actions on their own
system.
Page 2 of 4
• LYPFT adds Oasis handover notes to the patient’s LYPFT care record as well
as a full record of the MDT discussion and any required action.
4. Real-Time Communication Channels
•
“Real time” communication will continue with Oasis staff able to contact LYPFT
staff by telephone to aid timely updates and queries.
5. Training and Governance
• Training on the use of the handover sheet will be provided to ensure all are
aware of the roles and responsibilities in each organisation.
• We will monitor compliance and effectiveness through audits and feedback
mechanisms.
In addition to the above, the CRISS team at LYPFT and Oasis staff are exploring the
possibility of Oasis staff having access to LYPFT’s electronic patient record. This will be
taken for further discussion through the operations meeting (described below).
We would also like to take this opportunity to describe the escalation processes and
monitoring we currently have in place to ensure formal communication, risk management,
and information sharing for patients admitted to the respite facility:
Referral Point – jointly attended by LYPFT and Oasis staff to share, handover, and discuss
issues of patient risk at the point of referral.
Book-in Meeting - jointly attended by LYPFT and Oasis staff to facilitate discussion and
sharing of patient risk-related concerns at the point of admission.
Joint Reviews - conducted jointly by LYPFT and OASIS staff at 48 hours, 96 hours (if
applicable), and 144 hours (if applicable) to ensure ongoing review and management of
patient risk during their stay.
Interface Meeting - held weekly between LYPFT and Leeds Oasis to discuss and share
information and concerns around patient risk.
Operations Meeting – previously held monthly and attended by members include staff from
LYPFT, Leeds Oasis and Integrated Care Board (ICB). The meeting provided a forum to
escalate risks impacting patient safety and service delivery. The meeting allowed strategic
operational oversight and will recommence in November 2025.
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Clinical Improvement Forum (CIF) Meetings – a monthly meeting that forms part of LYPFT
clinical governance structures is attended by Leeds Oasis management to provide additional
oversight and communication.
We would be pleased to provide any further information or clarification required. If you feel
that a meeting with staff to discuss any of the above would be helpful, please do not hesitate
to contact us.
I hope this response provides assurance of improvement, consistent with the concerns
highlighted in the Regulation 28 and we thank you for the opportunity to further reflect on the
learning following the sad death of Mr Marsh.
Yours Sincerely
Chief Executive
Leeds & York Partnership NHS Foundation Trust
Chief Executive
Leeds Survivor-Led Crisis Service
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