Source · Prevention of Future Deaths
Joshua Rennard
Ref: 2022-0091
Date: 7 Mar 2022
Coroner: Stephen Eccleston
Area: South Yorkshire (West)
Responses identified: 0 / 1
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Significant and systemic delays in actioning recommendations for Mental Health Act assessments place individuals with mental illness at risk of harm and death.
Date
7 Mar 2022
56-day deadline
16 May 2022
Responses identified
0 of 1
Coroner's concerns
Significant and systemic delays in actioning recommendations for Mental Health Act assessments place individuals with mental illness at risk of harm and death.
View full coroner's concerns
The MATTERS OF CONCERNS are as follows: 5.1 I received evidence from Ms. Spence and Ms. Pawson of the Mental Health Care Trust as follows. 5.2 Joshua had been known to mental health services (MHS) since about 2018. He was again referred to MHS on 26.06.21 and was made subject to an order for assessment under S2 Mental Health Act 1983 (MHA) on 26.07.21. He was discharged to the Sheffield Home Treatment Team on 11.08.21. 5.3 A mental health nurse, Ms. Spence, was allocated on 31.08.21. 5.4 The view was reached on 18th August 2021 that Joshua’s deteriorating mental health and level of risk meant that he should be assessed for detention for assessment under s2 MHA. This was not actioned until 26th August 2021. On that date, a warrant was applied for which contained errors which invalidated it. Nevertheless, Joshua was assessed, and the decision taken that he did not require a section as at that date. 5.5 Joshua hanged himself on 29.09.21. 5.6 My particular concern is the delay between a professional view being reached that Joshua required assessment for S2 detention on 18th August 2022 and the actioning of that decision on 26th August 2021, 8 days later. The evidence was that Joshua was at risk during this period although I did not find that the delay specifically contributed to Joshua’s death on 29th September 2021. I am specifically concerned that others might be placed at risk if similar delays arise in the future.
5.7 Further evidence was given that this delay was due to the way that the required Approved Mental Health Professional (AMHP) input was allocated or available. The evidence was that delays of this nature were not unusual and that people with mental illness are at risk during these gaps and delays. I considered that such delays in promptly progressing recommendations for assessments for Section could place people at risk of harm and death. 5.8 I require you to report explaining (1) what action will be taken to prevent the risk of deaths while a person who is recommended for assessment for section is waiting for the assessment to take place and (2) what action will be taken to eliminate such waits for assessment.
5.7 Further evidence was given that this delay was due to the way that the required Approved Mental Health Professional (AMHP) input was allocated or available. The evidence was that delays of this nature were not unusual and that people with mental illness are at risk during these gaps and delays. I considered that such delays in promptly progressing recommendations for assessments for Section could place people at risk of harm and death. 5.8 I require you to report explaining (1) what action will be taken to prevent the risk of deaths while a person who is recommended for assessment for section is waiting for the assessment to take place and (2) what action will be taken to eliminate such waits for assessment.
Report sections
Investigation and inquest
On 13th October 2021 I commenced an investigation into the death of Joshua Adey Rennard aged
33. The investigation concluded at the end of the inquest on 18th March 2022. The conclusion of the inquest was:
Ia) Hanging I reached a conclusion of suicide.
33. The investigation concluded at the end of the inquest on 18th March 2022. The conclusion of the inquest was:
Ia) Hanging I reached a conclusion of suicide.
Circumstances of the death
Joshua hanged himself at his parents’ home on 29th September 2021.
Copies sent to
of Joshua and also to The Sheffield CCG and the Director of Adult Social Care for Sheffield Council
Similar PFD reports
Related inquiry recommendations
Report details
- Reference
- 2022-0091
- Date of report
- 7 March 2022
- Coroner
- Stephen Eccleston
- Coroner area
- South Yorkshire (West)
Responses identified
Responses identified
0 of 1
1 response not yet linked
Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 16 May 2022.
Sent to
- Sheffield Health and Social Care NHS Foundation Trust