Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, written 1 Sep 2015. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 1 Sep 2015 |
|---|---|
| Deceased | Darren Browne |
| Coroner | Andrew Harris |
| Coroner area | London Inner (South) |
| Category | Other related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
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 Re Darren Brown, 00613-14 (died 03.03.14) (MM) THIS REPORT IS BEING SENT TO: 1. Sir Bernard Hogan-Howe, The Commissioner of Police of the Metropolis, New Scotland Yard, 8-10 Broadway, London SW1H OBG CORONER Iam Andrew Harris, Senior Coroner, London Inner South 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. INQUEST On 15" May 2014 I opened an inquest into the death of Mr Darren Brown, who died on 3 March 2014 at Lambeth Hospital. | | | | I concluded the inquest at a full hearing on 6 August 2015. The medical cause of death was ta Asphyxia 1b Ligature compression of the neck. The jury concluded he committed suicide CIRCUMSTANCES OF THE DEATH The circumstances were recorded in a narrative and included this: “There were a number of contributory factors leading to his death. Documented mental health issues including Aspergers syndrome and depression, his lack of social support and interaction and the deaths and separation from close family members. Other factors included imminent appearance at court...” The court also heard that he was about to appear at the police station but the evidence was mixed whether he was stressed or not about this. It would appear from the evidence that he knew he was to be charged with a criminal offence, before he committed suicide. CORONER’S CONCERNS During the course of the inquest the evidence revealed that he was prevented from contacting his mother or sister and that they were not even aware of the circumstances nor consulted about this decision. The evidence suggested that both the deceased and his relatives regretted the complete cessation of communications. Mr Brown was an extremely vulnerable adult and professional evidence was heard about his high risk of suicide and his incapacity to make friends and how crucial his reliance was on his mother and sister. The prevention of any communication was a factor which led to his taking his life. The MATTER OF CONCERN is as follows. - Whilst the details of the offences being investigated were not disclosed to the jury, but were known to the coroner, it is clear that there may have been good reason to restrict contact between members of the family. However the matter of concern is whether in making that decision, proper consideration was given to balancing those needs or risks with the very acute needs of and risks to the deceased. It is of great public concern that the needs and risks of prospective defendants, who are (not infrequently) suffering from mental health problems and are vulnerable are taken into account in setting bail conditions or making restrictions on support to them. The inquest did not permit exploration of the possible charges or the decisions of the police, mindful of the proper scope of enquiry and the need to respect Convention rights about what may enter the public domain. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe that that if the MPS did not consider the needs and risks of this mentally ill and vulnerable defendant, in making the decision to restrict contact with his family, that the MPS should consider whether any review is indicated of the way similar decisions are taken in the future. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by Friday October 23" 2015. 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, If you require any further information about the case, please contact the case officer, Ms Marianne Mitulescu . If you require further information about the process of responding to this report my |__| clerk 0 whom your response should be sent. COPIES and PUBLICATION I have sent a copy of my report to the following Interested Persons: | Bevan Brittan LLP solicitors for family and for SLAM Trust. I am also sending a copy Di _ _ _ _ Mi esident of the Faculty of Forensic and Legal Medicine and the Dame Ann Owers Chair of IPCC. Iam also 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. 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.
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