Source · Prevention of Future Deaths

Melanie Lowe

Ref: 2016-0404 Date: 11 Nov 2016 Coroner: Caroline Beasley-Murray Area: Essex Responses identified: 1 / 1 View PDF

The Trust's action plan is inadequate, lacking specific detail, supporting evidence, and requiring a far more rigorous approach to prevent future deaths.

Date 11 Nov 2016
56-day deadline 16 Apr 2017 est.
Responses identified 1 of 1
Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary
The Trust's action plan is inadequate, lacking specific detail, supporting evidence, and requiring a far more rigorous approach to prevent future deaths.
View full coroner's concerns
_ (1) The trust's action plan is very basic, lacking specific detail. Some elements are blank and there is an absence of supporting evidence: A far more rigorous action plan is required in an effort to prevent future deaths such as Melanie's Cont.

Responses

1 respondent
Response NHS / Health Body
5 Jul 2017 PDF
Action Taken

The Trust updated its action plan with supporting evidence and will complete a further audit to ensure that all the actions identified have been embedded into practice. (AI summary)

View full response
Dear very Sad

Report sections

Investigation and inquest
On 2 March 2016 commenced an investigation into the death of Melanie Ellen Lowe: The investigation concluded at the end of the inquest on 9 November 2016. The conclusion of the inquest was that Melanie Ellen Lowe killed herself: The jury added a narrative conclusion Melanie's risk of self harm/suicide was not properly and adequately assessed and reviewed. Adequate and appropriate precautions were not taken t0 manage her risk of self harm/suicide
Circumstances of the death
Melanie Lowe, a 41 year old lady had suffered from somatization disorder over a long period of time and was sectioned under s2 MHA in the Derwent Centre Harlow. On the morning of 2 March she was found unresponsive in her room and she was found to have a wad of tissues obstructing her airway: She died in Princess Alexandra Hospital Harlow later that day: Both the trust's own Serious Incident Investigation report and the independent psychiatric report provided by an independent psychiatrist instructed by the court were highly critical of the care provided to Melanie in the time leading up to her death
Action should be taken
In my opinion action should be taken to prevent future deaths and believe you and your organisation have the power to take such action. YouR RESPONSE You are under a to respond to this report within 56 of the date of this report;, namely by 16th January 2017 . |, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action: Otherwise you must explain why no action is proposed:
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Murray duty days duty

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Report details

Reference
2016-0404
Date of report
11 November 2016
Coroner
Caroline Beasley-Murray
Coroner area
Essex

Responses identified

Responses identified 1 of 1
All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 16 Apr 2017 (estimated).

Sent to

North Essex University NHS Trust

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