Evidence
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Date of report: 20/12/2023
Ref: 2024-0005
Deceased name: Ryan Evans
Coroner name: Darren Stewart
Coroner Area: Hampshire, Portsmouth and Southampton
Category: Suicide (from 2015) | Mental Health related deaths
This report is being sent to: Frimley Health NHS Foundation Trust |Surrey and Borders Partnership NHS Foundation Trust
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS | |
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THIS REPORT IS BEING SENT TO: CEO, Frimley Health NHS Foundation Trust (FPH) CEO, Surrey and Borders Partnership NHS Foundation Trust (SABP) |
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1 | CORONER I am Darren Stewart OBE, Assistant Coroner, for the Coroner Area of Hampshire, Portsmouth and Southampton |
2 | CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. |
3 | INVESTIGATION and INQUEST On 4th April 2018 I commenced an investigation into the death of Ryan John EVANS. The investigation concluded at the end of the inquest on 23rd January 2023. The inquest was heard with a Jury. Mr. EVANS died of: The jury returned the following narrative conclusion: Ryan was adopted at age two along with his older brother and sister and were brought up in a close family unit with his adoptive parents, following a traumatic early childhood. Ryan’s mental health had deteriorated over approximately seven months due to a number of contributory factors. Ryan was arrested on 2nd April outside ACASA offices for: Ryan John Glyn EVANS took his own life while suffering from the diagnosed medical illness of depression. |
4 | CIRCUMSTANCES OF THE DEATH The circumstances of the death are recorded in the Jury’s Narrative Conclusion. |
5 | CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. The concerns raised were as follows: Referral to Psychiatric Liaison Services for patients presenting with self-harm injuries and suicidal ideation (including those in Police custody) at Frimley Park Hospital A&E, including the extent to which the NICE guidance is complied with or provides effective guidance to staff in such circumstances. The conduct of Mental Health Assessments in a custody setting by liaison and diversion staff including the adequacy of policy and guidelines relating to triggers to conduct such assessments and the manner in which refusals are dealt with. The passage of information both between custody staff, as well as with healthcare staff in relation to concerns of a mental health nature for a detained person including the extent to which the custody record is used as an effective means to communicate concerns/observations of detained persons mental health. The process of release of a vulnerable detained person following disposal, including interaction with family or other persons collecting the detained person. I received further evidence in writing from the Interested Persons’ subsequent to the completion of the Inquest in relation to these concerns. This evidence included responses from Hampshire Constabulary and Southern Health NHS Foundation Trust concerning the measures which have been put in place to address the failures identified during the course of the Inquest with respect to concerns at b – d (above). I was satisfied that these measures addressed the concerns in relation to each of these Interested Persons. I also received evidence from the Frimley Health NHS Foundation Trust concerning the measures which that organisation had undertaken in their area of responsibility to address my concern detailed at a (above). This evidence has not allayed my concern in relation to a (above). 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. Evidence received from the police officers accompanying Mr. EVANS during his attendance at Frimley Park Hospital provided that: a. Mr. EVANS presented with a large fresh cut on his arm and also cuts on his legs which were identified by him as being from self-harm with hospital staff noting that the larger mark on the arm might require stitching. Police officers stated that Mr. EVANS was open with hospital staff about his feelings of self-harm depression, and thoughts of ending his own life. Officers further recalled that hospital staff noticed and commented on the self-harm marks on Mr. EVANS’ arms, including whilst staff were dressing a recent self- harm wound on Mr. EVANS’ left arm. Officers also recalled Mr. EVANS commenting when offered food by hospital staff that he would rather starve to death. One of the accompanying police officers expressed surprise at the fact that Mr. EVANS was not subject to a mental health referral or assessment, in the context of him commenting to multiple hospital staff members about his self-harm actions and ideation. An emergency department consultant at Frimley Park gave evidence which suggested that no mental health assessment was or would have been necessary where Ryan’s presenting complaint was recorded as chest pains rather than of self- harm and/or suicidal ideation. Although self-harm had been noted in the records, no explanation could be provided for why Ryan’s suicidal ideation had not been recorded. The consultant was further questioned in relation to the 2006 NICE Guidelines “Self-Harm: The short term physical and psychological management and secondary prevention of self-harm in primary and secondary care” which are national guidelines that ought to feed into practice at the hospital. These guidelines provide that “Following triage patients who have self-harmed should receive the requisite treatment for their physical condition, undergo risk and full psychosocial needs assessment and mental state examination, and referral for further treatment and care as necessary” and “All people who have self harmed should be offered an assessment of needs, which should be comprehensive and include evaluation of the social, psychological and motivational factors specific to the act of self-harm, current suicidal intent and hopelessness, as well as a full mental health and social needs assessment.” Evidence received during the course of the Inquest was not able to reconcile the contradiction between the NICE guidelines on self-harm and Mr. EVANS having had no mental health assessment despite obvious signs of self-harm and further evidence of disclosure of suicidal ideation. The jury in their Narrative Conclusion found that ‘Despite evidence of self-harm, no mental health assessment was carried out at this point.’ I remain concerned as to how such a situation would be avoided if a patient presented again in similar manner to Mr. EVANS. The additional evidence on PFD matters provided by Frimley Health NHS Foundation Trust does not refer to or address the NICE guidelines on self-harm or explain what would now be done differently were a patient such as Mr. EVANS were to be seen again. The Frimley Health NHS Foundation Trust additional evidence refers to matters being in the process of introduction and new referral criteria with Surrey and Borders Partnership NHS Foundation Trust, but this does not explain how this would prevent the future risk of a patient such as Mr. EVANS leaving the hospital without a mental health assessment. |
6 | ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you and/or your organisation have 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 29th February 2024. 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 namely: Family of Ryan John Glynn EVANS Hampshire Constabulary [REDACTED], Hampshire Constabulary [REDACTED], Hampshire Constabulary Southern Health NHS Foundation Trust [REDACTED], Former SHFT Employee, Registered Mental Health Nurse MITIE [REDACTED], Former MITIE Employee, Health Care Practitioner (HCP) Alexander’s Care and Support Agency (ACASA) IOPC I may also send a copy of your response to any other person who I believe may find it useful or of interest. 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. |
9 | 20th December 2023 Darren Stewart OBE |
The post Ryan Evans: Prevention of future deaths report appeared first on Courts and Tribunals Judiciary.
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