Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, written 30 Nov 2015. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 30 Nov 2015 |
|---|---|
| Deceased | Stephen Adams |
| Coroner | Geraint Williams |
| Coroner area | Worcestershire |
| Category | Hospital Death (Clinical Procedures and medical management) 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.
Worcestershire Coroner's Court The Civic Martins Way Stourport on Severn Worcestershire DY13 8UN G U Williams LLB HM Senior Coroner My Ref: GUW/TW/W1365.15 Date: 30 November 2015 Your Ref: Judge Peter Thornton QC Chief Coroner's Office, 11th Floor Thomas More Building Royal Courts of Justice, Strand, London, WC2A 2LL By Email only : chiefcoronersoffice @iudiciary gsi gov,uk Dear Sir Re: Stephen Martin ADAMS deceased Regulation 28: Report to Prevent Future Deaths | enclose herewith my Regulation 28 Report to Prevent Future Deaths. Yours sincerely GU Williams Enc: ANNEX A REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Worcestershire Health and Care NHS Trust 3. CORONER | am Geraint Urias Williams, Senior Coroner, for the coroner area of Worcestershire CORONER'S LEGAL POWERS | 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. INVESTIGATION and INQUEST On 23" June 2015 | commenced an investigation into the death of Stephen Martin ADAMS then aged 58 years. The investigation concluded at the end of the inquest on 23 November 2015. The conclusion of the inquest was suicide the medical cause of death being hanging CIRCUMSTANCES OF THE DEATH Mr Adams was being cared for by the Home Treatment Team of the Worcestershire Health and Care NHS Trust during which time he committed suicide by hanging himself at his home. 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. The MATTERS OF CONCERN ere as follows. - (1) It emerged during the inquest that the Risk Assessment document completed by the Mental Health Liaison Team worker was not complete in as much as the box indicating the assessment of suicide risk had not been completed. The witness indicated that many workers do not complete this box and the assessment of risk is to be extrapolated from the actions taken by the worker No where on the document is the assessment of risk to be found. (2) in my opinion action should be taken to prevent future deaths and | believe you have the od fully reser ect ction specifically to ensure that the assessment of risk is property and fully recorded on the assessment paperwork, YOUR RESPONSE ou are under @ duty to respond to this report within 56 days of the date ofthis report. namely by 25" January 2016 |, 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. COPIES and PUBLICATION pave sent a copy of my report to the Chief Coroner and to the following Interested Persons Mrs Fox-Adams. | have also Sent it to Chief Executive Trust, Chief Coroner who may find it useful or of interest. |1am also under a duty to send the Chief Coroner a copy of your response. tare 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 i neeful 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. —_ SZ—_3 rr GU Williams 30" day of November 2015 H M Senior Coroner
See every Prevention of Future Deaths report matching Hospital Death (Clinical Procedures and medical management) related deaths, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.