Source · Prevention of Future Deaths
Terry Latimer
Ref: 2017-0178
Date: 1 Jun 2017
Coroner: Paul Kelly
Area: North Lincolnshire and Grimsby
Responses identified: 0 / 1
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A safeguarding notice with a request for Mental Health Services referral was not actioned. There was a lack of clarity among staff on whether such notices required follow-up or were just for information.
Date
1 Jun 2017
56-day deadline
29 Sep 2017 est.
Responses identified
0 of 1
Coroner's concerns
A safeguarding notice with a request for Mental Health Services referral was not actioned. There was a lack of clarity among staff on whether such notices required follow-up or were just for information.
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.
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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).
Sent to
- North Lincolnshire Council