Source · Prevention of Future Deaths

Mark Ravensdale

Ref: 2025-0400 Date: 16 May 2023 Coroner: Abigail Combes Area: South Yorkshire (West District) Responses identified: 1 / 1 View PDF

Mental health services failed to directly engage with the deceased to properly and adequately assess his mental health condition.

Date 16 May 2023
56-day deadline 11 Jul 2023
Responses identified 1 of 1
Suicide (from 2015)

Coroner's concerns

AI summary
Mental health services failed to directly engage with the deceased to properly and adequately assess his mental health condition.
View full coroner's concerns
There were no attempts by mental health services to speak to Mark directly to properly and adequately assess his mental health condition.

Responses

1 respondent
South West Yorkshire Partnership NHS Trust NHS / Health Body
12 Jul 2023 PDF
Action Planned

The Trust will develop and implement a triage checklist for their Single Point of Access (SPA) teams, with an initial study of its impact undertaken after 6 months of implementation. This is in response to concerns about direct contact with individuals during triage. (AI summary)

View full response
Dear Ma’am, Regulation 28 Response – Mark Ravensdale We write in response to the Regulation 28 report following the inquest touching the death of Mr Mark Ravensdale. We would like to start this response by offering Mr Ravensdale’s family our sincere condolences for their loss. As part of our response, the Trust does not intend to provide any information in respect of the clinical rationales in Mr Ravensdale’s care. We hope the information supplied in this response provides assurance that the Trust has carefully considered the concerns raised and will take appropriate action to address them. There were no attempts by mental health services to speak to Mark directly to properly and adequately assess his mental health condition The Trust’s Single Point of Access (SPA) teams triage approximately 2000 referrals per month. It is therefore essential that all referrals undergo an initial triage by a qualified mental health professional, with the support of the multi-disciplinary team as required, in order to establish an individual’s mental health needs, the most suitable plan for meeting any identified mental health needs and the urgency and priority of any assessment required. In addition to establishing the urgency and nature of the response, the SPA triage process will determine whether a full comprehensive assessment is required. The SPA triage process is aligned with national standards in the form of the UK Mental Health Triage (MHT) Scale Guidelines (Sands, Elsom & Colgate 2015). The triage process would commonly involve direct contact with the person referred unless there are circumstances where it is clinically appropriate to carry out triage using the clinical records,

alongside information from professionals and carers working with the individual. This is particularly appropriate when other agencies are directly involved in delivering care and where the person has had recent assessments. Following receipt of the Regulation 28 report the Trust undertook a review of the SPA triage process specific to your concern, led by the Associate Director of Operations, Adults and Older People Mental Health Care Group. It was identified that, although the outcome of any triage process is reached based upon an evidence-based approach in line with the UK Mental Health Triage (MHT) Scale Guidelines and a practitioner’s own clinical assessment, further guidance would support a practitioner to identify when direct contact with the person referred may be clinically indicated. The Trust will therefore develop and implement a triage checklist in respect of the review’s findings. A Plan, Do, Study, Act (PDSA) cycle process will be applied to the implementation of the triage checklist. PDSA cycles provide a model of improvement framework to support change to services and care delivery. PDSA stands for:
• Plan – what you are going to do
• Do – what you have planned
• Study – the results of your actions
• Act – on the results and make improvements An initial study of the triage checklist impact upon service and care delivery will be undertaken following 6 months of the checklist’s implementation, with appropriate actions taken as identified by the study. I do hope the above information is of assistance and answers the concerns raised within your Regulation 28 report following the sad death of Mr Mark Ravensdale.

Report sections

Investigation and inquest
On 26 April 2022 I commenced an investigation into the death of Mark Ravensdale born on 2 January 1967. The investigation concluded at the end of the inquest on 2 February 2023. The conclusion of the inquest was:- Death by suicide The medical cause of death was: 1a: Hanging
Circumstances of the death
Mark Ravensdale had suffered with mental health conditions for a long period of time. Following one attempt to die by suicide he was placed into a care setting in order to support him before being moved into his own premises. He had a number of difficulties within that setting and continued to suffer with mental health challenges. His GP referred him into mental health services for assessment however when the services made contact with the home he was residing in Mark was not present at the home. The workers spoke to care staff but did not follow up with Mark afterwards and discharged him without speaking to him at any point. Shortly after this Mark was found hanged and his death was by suicide.

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Report details

Reference
2025-0400
Date of report
16 May 2023
Coroner
Abigail Combes
Coroner area
South Yorkshire (West District)

Responses identified

Responses identified 1 of 1
All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 11 Jul 2023.

Sent to

South West Yorkshire Partnership NHS Foundation Trust

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