Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, written 14 Dec 2015. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 14 Dec 2015 |
|---|---|
| Deceased | Julie Rose |
| Coroner | Chris Morris |
| Coroner area | Kent (Central and South East) |
| Category | Mental Health 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
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO: Ms Angela McNab, Chief Executive, Kent and Medway
NHS and Social Care Partnership Trust ("the Trust").
1 | CORONER
{am Christopher Morris, assistant coroner for the coroner area of Central & South East
Kent
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 29th April 2015, an inquest was opened into the death of Julie Margaret Rose who
was found dead on 26th April 2015, aged 54 years. | held a Pre-Inquest Review on 2nd
September 2015, and conducted an inquest on 9th December 2015 at Folkestone
Magistrates Court.
The conclusion of the inquest was suicide, the medical cause of death being
suspension.
4 | CIRCUMSTANCES OF THE DEATH
On 24th April 2015, Miss Rose (who was well-known to the Trust's Community Mental
Health and South East Kent Crisis Resolution Home Treatment Team as a result of long-
standing depression, anxiety and Obsessive Compulsive Disorder) was brought to St
Martin's Hospital, Canterbury by police under s136 Mental Health Act following a
concern that she intended to take her own life.
Following assessment by an Approved Mental Health Professional, Consultant
Psychiatrist and independent (s12) doctor, Miss Rose was discharged from s136 with a
plan in place for support at home by the Crisis Resolution Home Treatment Team and a
medication review.
On 25th April 2015, Miss Rose was visited at home by two members of the Crisis
Resolution Home Treatment Team who noted her to be low in mood. Miss Rose
agreed to undertake tasks and techniques intended to improve her state of mind. At
approximately 14:50, a supportive telephone call was made to Miss Rose who reported
she felt suicidal. The specialist support worker who spoke with Miss Rose again made
suggestions as to steps she could take to improve her mood.
Further attempts to contact Miss Rose by telephone at 17:00, 18:00 and 22:30 were
unsuccessful, as was an attempted home visit at around 09:25 on 26th April 2015.
Although at least one team member expressed concerns that it was unusual not to be
able to contact Miss Rose, no attempts were made to contact family members who
also supported her.
Additional attempts were made without success to contact Miss Rose by telephone,
and following a further attempted home visit at around 16:00 (over 24 hours after
Trust staff had managed to make any contact with Miss Rose), Kent Police was
contacted and a welfare check requested.
Officers forced entry to Miss Rose's home, where she was found dead.
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 will occur unless action is taken. In the
circumstances it is my statutory duty to report to you.
Whilst | heard evidence at the inquest of the considerable efforts the Trust has made to
reflect on the circumstances of Miss Rose's death and mitigate the risk of similar deaths
occurring, it is my opinion that there remain matters of concern.
These residual MATTERS OF CONCERN are as follows. —
(1) Although the Trust's Unable to Make Contact Protocol ("the Protocol") has been
reviewed since Miss Rose's death, | am concerned that it is insufficiently clear as to
when Crisis Resolution Home Treatment Team members should request a police
welfare check in respect of patients who have been identified as ‘Red' for the purposes
of the Trust's R A G Rating System.
In particular, | am concerned the Protocol does not specifically stipulate circumstances
where a request for a welfare check is mandatory (for example, after a certain period
of time has elapsed since contact was last made, and / or after a certain number of
attempts at contact and / or after attempts at telephone contact and a home visit have
both been unsuccessful);
(2) In the course of the hearing, | heard evidence that the Protocol has been
‘reinforced! across the Crisis Resolution Home Treatment Team. Notwithstanding this,
a shift co-ordinator who gave evidence was clearly not conversant with the Protocol,
raising questions as to the adequacy of the steps taken by the Trust to date in this
respect.
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and | believe your
organisation has the power to take such action.
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report,
namely by Ist February 2016. |, the coroner, may extend the period.
Your response must contain details of action taken or proposed to be taken, setting out
| have sent a copy of my report to the Chief Coroner and to the following Interested
Persons:
1.
2.
| have also sent it to the Care Quality Commission who may find it useful or of interest.
lam 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.
14th December 2015
Ce;
ts Katriona Learmond - Head of Legal Services (Solicitor)
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