Source · Prevention of Future Deaths
Greg Hutchins
Ref: 2018-0129
Date: 12 Sep 2018
Coroner: Sean McGovern
Area: Warwickshire
0 responses identified · 1 indexed addressee
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AI-generated concerns summaryThe coroner noted a lack of clear purpose and documentation for telephone triage, including no notes, system updates, or staff recollection. There was also no national system for rapid information sharing for patients from outside the local area.
Date
12 Sep 2018
56-day deadline
7 Nov 2018 est.
estimated from the report date
Responses identified
0 of 1
Coroner's concerns
The coroner noted a lack of clear purpose and documentation for telephone triage, including no notes, system updates, or staff recollection. There was also no national system for rapid information sharing for patients from outside the local area.
View full coroner's concerns
(1) the staff member who conducted the telephone triage had no recollection of the triage whatsoever (2) no contemporaneous of the triage were made (3) no subsequent notes were made of the triage (4) no update regarding the triage was made in RIO system (5) the purpose of the telephone triage was unclear – it was described as not being a mental health assessment
(6) Mr Hutchins was from outside the Birmingham area and I hear evidence that no national system exists for rapid information sharing
(6) Mr Hutchins was from outside the Birmingham area and I hear evidence that no national system exists for rapid information sharing
Report sections
Investigation and inquest
On 4 September 2017 I commenced an investigation into the death of Greg HUTCHINS. The investigation concluded at the end of the inquest on 2 May 2018 2018. The conclusion of the inquest was that Mr Hutchins committed suicide.
Circumstances of the death
Mr HUTCHINS committed suicide on 28 August 2017 in a hotel room at Day’s Inn, Corley Services Warwickshire. He had suffocated himself with a plastic bag and helium. Thirteen days earlier he had contact with the Street Triage team and I set out my concerns regarding that contact below
Copies sent to
Aunt of the Deceased) and(a close friend of Deceased)
Similar PFD reports
Report details
- Reference
- 2018-0129
- Date of report
- 12 September 2018
- Coroner
- Sean McGovern
- Coroner area
- Warwickshire
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: 7 Nov 2018 (estimated from the report date).
Sent to
- Birmingham & Solihull Mental Health Trust