Source · Prevention of Future Deaths
Demi Williams
Ref: 2016-0464
Date: 22 Dec 2016
Coroner: R Brittain
Area: London Inner (North)
Responses identified: 0 / 1
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Despite general risk assessments, no specific consideration was given to the method of self-harm Ms Williams had previously described. This critical oversight and its omission from the Trust's investigation risk missing crucial learning opportunities.
Date
22 Dec 2016
56-day deadline
16 Feb 2017 est.
Responses identified
0 of 1
Coroner's concerns
Despite general risk assessments, no specific consideration was given to the method of self-harm Ms Williams had previously described. This critical oversight and its omission from the Trust's investigation risk missing crucial learning opportunities.
View full coroner's concerns
The MATTERS OF CONCERN are as follows –
(1) The method that Ms Williams later used to take her own life was specifically described to CANDI during the assessment process in January 2016. I am concerned that, although a general risk assessment was undertaken on several occasions, there was no consideration of the specific risk which Ms Williams had previously described.
Furthermore, I am concerned that, as it stands, the Trust’s own investigation does not reflect this issue and that the potential for further learning from Ms Williams’
death could be missed.
(1) The method that Ms Williams later used to take her own life was specifically described to CANDI during the assessment process in January 2016. I am concerned that, although a general risk assessment was undertaken on several occasions, there was no consideration of the specific risk which Ms Williams had previously described.
Furthermore, I am concerned that, as it stands, the Trust’s own investigation does not reflect this issue and that the potential for further learning from Ms Williams’
death could be missed.
Report sections
Investigation and inquest
Demi Williams died on or around 11 March 2016, aged 22 years, from the consequences of helium inhalation. An inquest into her death was opened on 22 March 2016 and concluded on 16 December 2016. I recorded a narrative conclusion, which is attached.
Circumstances of the death
Ms Williams was detained by CANDI under the Mental Health Act in January 2016, following the development of new psychotic symptoms.
During the assessment process Ms Williams stated she had purchased helium gas with the intention of using it to kill herself. Her mental health improved and she was eventually discharged home in early March 2016. However, she was still experiencing suicidal thoughts (but no plans to harm herself) and some anxiety about being back at her own residence. At no point was it was it clarified whether the helium she had purchased had been delivered to her flat.
Concerns were raised after Ms Williams did not attend a planned appointment and she was found deceased in her flat on 15 March 2016. Her death resulted from inhalation of helium. A delivery note dated 6 January 2016 was found by police officers who investigated her death.
CANDI undertook an investigation into Ms Williams’ death. This was available to me in draft form at the inquest. The conclusions set out a main learning point regarding making attempts to contact patients’ relatives. There was no reference to the lack of specific risk assessment regarding Ms Williams’ potential access to helium.
During the assessment process Ms Williams stated she had purchased helium gas with the intention of using it to kill herself. Her mental health improved and she was eventually discharged home in early March 2016. However, she was still experiencing suicidal thoughts (but no plans to harm herself) and some anxiety about being back at her own residence. At no point was it was it clarified whether the helium she had purchased had been delivered to her flat.
Concerns were raised after Ms Williams did not attend a planned appointment and she was found deceased in her flat on 15 March 2016. Her death resulted from inhalation of helium. A delivery note dated 6 January 2016 was found by police officers who investigated her death.
CANDI undertook an investigation into Ms Williams’ death. This was available to me in draft form at the inquest. The conclusions set out a main learning point regarding making attempts to contact patients’ relatives. There was no reference to the lack of specific risk assessment regarding Ms Williams’ potential access to helium.
Copies sent to
Police Service and the Care Quality Commission
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Report details
- Reference
- 2016-0464
- Date of report
- 22 December 2016
- Coroner
- R Brittain
- Coroner area
- London Inner (North)
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: 16 Feb 2017 (estimated).
Sent to
- Camden and Islington NHS Foundation Trust