Source · Prevention of Future Deaths

Emma Pring

Ref: 2022-0105 Date: 3 Apr 2022 Coroner: Catherine Wood Area: Mid Kent and Medway 1 response identified · 1 indexed addressee View PDF

AI-generated concerns summaryThe coroner noted that older versions of anti-ligature clothing, which the deceased used to form a ligature, remain in circulation and may provide false reassurance to staff regarding self-harm risk, despite subsequent product improvements by the manufacturer.

Date 3 Apr 2022

56-day deadline 1 Jun 2022 stated in the report

Responses identified 1 of 1

Hospital Death (Clinical Procedures and medical management) related deaths Mental Health related deaths Product related deaths Suicide (from 2015)

Coroner's concerns

AI summary

The coroner noted that older versions of anti-ligature clothing, which the deceased used to form a ligature, remain in circulation and may provide false reassurance to staff regarding self-harm risk, despite subsequent product improvements by the manufacturer.

View full coroner's concerns

(1) Evidence given at the inquest revealed that Emma was wearing items of clothing manufactured by your company which are made in such a way as to reduce the risk of using the clothing to self harm. The evidence heard that the clothing was commonly referred to as “anti clothing”, or “safety clothing”

as well as “seclusion wear”. It was clear from the evidence that the product was made to reduce the risk of self harm and could not eliminate the risk and that wearers still required supervision. However, in practice it may have provided some reassurance to staff that could not be made from the clothing.

(2) Evidence was heard that Emma had sadly somehow managed to use components of her anti clothing to form a ligature to end her life.

(3) The evidence given at the inquest was clear that since the notification of Emma’s death your company have gone to considerable efforts and are to be commended in relation to the changes you have made to your product to further reduce the risk of the products being used to self harm.

(4) Further evidence was given that some of the products like those Emma wore are still in circulation and whilst Cygnet are aware and possibly NHS Providers via Cygnet reporting the issue to them there remain risks that users of those products may use them in the same way. This risk may be increased following the publication of the circumstances of Emma’s death.

(5) At the inquest evidence from your company indicated that you were still considering what, if any, action may be required regarding the items manufactured prior to the changes which remain in circulation.

Responses

1 respondent

Ramsdens Solicitors

Indexed date: 27 May 2022 PDF

AI-classified response stance Action Taken

AI-generated response summary

• The client notified customers who had been supplied with similar products. • The client recommended customers check their stock of seclusion garments for damage, especially those supplied before April 2021, and dispose of damaged items. • The client reviewed and updated the care instructions issued with seclusion products.

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Dear Madam Inquest into the death of Emma Pring - Regulation 28 Report to prevent future deaths Our Client - Interweave Textiles Limited As you know, we act for Interweave Textiles Limited. We refer to your regulation 28 report dated 3 April 2022. Our client has already (and by 19 May 2022) completed taking steps directly to notify in writing those customers who had been supplied with products of the same sort as were worn by Emma Pring. Our client expressly referred to the destruction of the waistband for use as a ligature, and has recommended that customers check their current stock of seclusion garments, especially garments supplied before April 2021, for any damage. Customers were also been reminded that all garments (whenever they were supplied) should be checked on each occasion before they are provided to service users, and that any seclusion garments that are showing significant wear and tear or any damage should be disposed of and replaced. Customers have also been reminded that garments should only be used in combination with supervision. In addition, our client has reviewed and updated the care instructions which it issues with seclusion products.

Direct Tel:

Direct Fax:

Ramsdens

Oakley House 1 Hungerford Road Edgerton HUDDERSFIELD

HD3 3AL Offices also at: Huddersfield Slaithwaite Holmfirth Elland Halifax Dewsbury Mirfield Wakefield Leeds York Milnsbridge Ramsdens Solicitors is a trading name of Ramsdens Solicitors LLP, a limited liability partnership registered in England and Wales, registration number OC316582, and is authorised and Doc Ref : regulated by the Solicitors Regulation Authority (00440420). A list of members is available for inspection at its Registered Office: Oakley House, Edgerton, Huddersfield, HD3 3AL. 2183297098 Ramsdens Solicitors uses the word “partner” to refer to a member of the LLP, or an employee or consultant with equivalent standing and qualifications.

Report sections

Investigation and inquest

On the 30th April 2021 an inquest was opened into the death of Emma Pring. At the inquest, which was heard with a jury and lasted seven days we heard from many of those involved in Emma’s short life. The jury concluded on 18th March 2022 with a narrative conclusion “Emma Pring died from asphyxiation caused by self application of a .”

Circumstances of the death

(1) Emma Pring was diagnosed as suffering from Emotionally Unstable Personality Disorder and Post Traumatic Stress Disorder following two incidences of rape in her late teens. Her mental health was such that she made several serious attempts to end her life and she had several hospital admissions both voluntary, and at times compulsory under the Mental Health Act. (2) She was admitted to Cygnet hospital, Maidstone under section 3 of the Mental Health Act to undergo treatment including Cognitive Behavioural and Dialectical Behavioural therapies. The latter had recently commenced and she had undergone the first imaginal exposure therapy when her health deteriorated and she used on the ward and was expressing wishes to self harm and end her life. She was placed on increased observations from every 30 to every 15 minutes and objects she could use to harm herself removed from her room and she was given “anti-clothing” to wear. (3) She was not placed on one to one observation and somehow managed to make a from the specialist clothing she had been wearing.

Similar PFD reports

Shared signals

Report details

Reference: 2022-0105
Date of report: 3 April 2022
Coroner: Catherine Wood
Coroner area: Mid Kent and Medway

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: 1 Jun 2022 (stated in the report).

Sent to

Interweave

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk.

Contains public sector information licensed under the Open Government Licence v3.0.