Prevention of Future Deaths reports · 2020
Regulation 28 report to prevent future deaths, written 9 Nov 2020. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 9 Nov 2020 |
|---|---|
| Deceased | REDACTED |
| Coroner | Caroline Topping |
| Coroner area | Surrey |
| Category | Suicide (from 2015) |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
IN THE SURREY CORONER’S COURT IN THE MATTER OF: __________________________________________________________ The Inquest Touching the Death of A Regulation 28 Report – Action to Prevent Future Deaths __________________________________________________________ THIS REPORT IS BEING SENT TO: • • Council 1 CORONER Domestic Abuse Management Board Surrey Police , Executive Director of Children Services Surrey County Caroline Topping HM Assistant Coroner, for the County of Surrey 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 An inquest into the death of December 2017, resumed on the 12th October 2020 and concluded on the 14th October 2020. I concluded with a narrative conclusion that: was opened on 6th died on the 29th November 2017 at . She had tied a ligature around her neck and died by hanging. She had drunk considerable amounts of alcohol and taken cocaine. It is not possible to determine whether she intended to kill herself. I concluded that the medical cause of death was: 1a. Hanging . 4 CIRCUMSTANCES OF THE DEATH died at her home address having consumed a considerable quantity of alcohol and cocaine. She tied a ligature around her neck and died by hanging. It was not clear if this was a cry for attention or help and whether she thought she might be found in time. 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. – The evidence showed that: 1. 2. 3. was being treated for depression by her general practitioner. She was prescribed anti-depressant medication. She had last been reviewed in February 2017. She was not open to secondary mental health provision. was the subject of a MARAC referral organised by the Surrey Police on the 14th June 2017 in respect of allegations of domestic violence and coercive control which made relating to her partner. general practitioner was not invited to contribute to the MARAC meetings held in July and August 2017. General Practitioners are not routinely invited to MARAC meetings. 4. The risks and the planned safeguarding measures identified by the MARAC were not communicated to the general practitioner. 5. The general practitioner responsible for treating made aware of the allegations of domestic abuse and coercion that made. mental health was not had children were removed from her care in and she was then involved in care proceedings. Her general practitioner was not made aware of this although it would have been a further significant stressor so far as her mental health was concerned. 6. . 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe your organisation has 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 5th January 2021. 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 Heathcote Medical Centre. I am 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. 9 Signed: Caroline Topping Dated this 9th November 2020.
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