Source · Prevention of Future Deaths
Caroline Scott
Ref: 2018-0155
Date: 21 May 2018
Coroner: Thomas Osborne
Area: Milton Keynes
0 responses identified · 1 indexed addressee
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AI-generated concerns summaryThe coroner identified inadequate out-of-hours emergency mental health services and noted that the emergency referral policy was not fully understood by all medical services in Milton Keynes.
Date
21 May 2018
56-day deadline
2 Sep 2018 est.
estimated from the Judiciary.uk publication date
Responses identified
0 of 1
Coroner's concerns
The coroner identified inadequate out-of-hours emergency mental health services and noted that the emergency referral policy was not fully understood by all medical services in Milton Keynes.
View full coroner's concerns
(1) That the provision of out of hours emergency service for mental health emergencies is inadequate (2) That the policy for emergency referrals is not fully understood by all medical services in Milton Keynes HM Coroners Office; Civic Offices; Saxon Gate East; Central Milton Keynes, MK9 3EJ Tcl 01908 254326 Fax 01908 253636 May prior cut
Report sections
Investigation and inquest
On 02/06/2017 commenced an investigation into the death of Caroline Antoinette Scott; aged 52_ The investigation concluded at the end of the inquest on 17"h 2018 The conclusion of the inquest was a narrative Conclusion: The deceased suffered from depression and had thoughts of suicide immediately _ to her death and had sought medical advice _ It was recognised that she was in crisis but there was a failure to carry out a mental health assessment that resulted in a lost opportunity to refer her for treatment: She was found hanging at her home on 30" May 2017. She was taken by ambulance to Milton Keynes University Hospital where she died on 2id June 2017 . The cause of death was: (a)Multi Organ Failure (b) Hypoxic Brain Injury following Hanging
2. Depression
2. Depression
Circumstances of the death
The deceased suffered a head injury in 2009, leading to depression for approximately 10 years, She had made previous attempts at suicide and was considered high risk On 30"h May 2017 she was found by family hanging in the garage. An ambulance was called and she was down and CPR commenced: She was transferred to Milton Keynes Hospital where she was treated until she passed away on 2h June 2017. In the weeks leading up to her death, she had contact with her GP; the accident and emergency department and the out of hours service.
Action should be taken
In my opinion action should be taken to prevent future deaths and believe you have the power to take such action.
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Report details
- Reference
- 2018-0155
- Date of report
- 21 May 2018
- Coroner
- Thomas Osborne
- Coroner area
- Milton Keynes
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: 2 Sep 2018 (estimated from the Judiciary.uk publication date).
Sent to
- Central and North West London Hospital NHS Trust