Source · Prevention of Future Deaths
Terry Latimer
Ref: 2017-0178
Date: 1 Jun 2017
Coroner: Paul Kelly
Area: North Lincolnshire and Grimsby
0 responses identified · 1 indexed addressee
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AI-generated concerns summaryThe safeguarding notice was not acted upon, specifically a request for referral to Mental Health Services, due to a lack of clarity among staff regarding whether the notice required follow-up action.
Date
1 Jun 2017
56-day deadline
29 Sep 2017 est.
estimated from the Judiciary.uk publication date
Responses identified
0 of 1
Coroner's concerns
The safeguarding notice was not acted upon, specifically a request for referral to Mental Health Services, due to a lack of clarity among staff regarding whether the notice required follow-up action.
View full coroner's concerns
The safeguarding notice was not acted upon either at all or appropriately. In particular a request accompanying the notice that the case be referred to Mental Health Services was not complied with. Evidence indicates lack of clarity in understanding whether the notice is just for information or should be followed up.
Report sections
Investigation and inquest
On 2nd June 2016 I began an investigation into the death of Terry Stapleton Latimer who died on 27th May 2016 by hanging. The investigation concluded with an inquest on 25th May 2017
Circumstances of the death
On 27th May 2016 the deceased was found dead by hanging at his home address. An inquest determined he died by suicide. The deceased received inpatient care in local psychiatric services between 18th April and 25th April 2016. On 15th May 2016 Police persuaded him to attend A&E at Scunthorpe General Hospital following safety concerns. The deceased did not wait to be seen.
A Safeguarding notification was generated by the attending Police Officer and submitted through usual procedures on 16th May 2016.
A Safeguarding notification was generated by the attending Police Officer and submitted through usual procedures on 16th May 2016.
Action should be taken
Namely a review with stakeholders (Police, A&E, mental health services) as to practices and procedures for safeguarding referral of mentally disordered persons known to be a threat to his or her own safety.
Similar PFD reports
Report details
- Reference
- 2017-0178
- Date of report
- 1 June 2017
- Coroner
- Paul Kelly
- Coroner area
- North Lincolnshire and Grimsby
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: 29 Sep 2017 (estimated from the Judiciary.uk publication date).
Sent to
- North Lincolnshire Council