Source · Prevention of Future Deaths

Huseyin Erdogan

Ref: 2015-0066 Date: 17 Feb 2015 Coroner: John Taylor Area: London (North) Responses identified: 0 / 1 View PDF

Key action plans developed following a death, with a November 2014 completion date, remained largely unimplemented by the time of the inquest, raising concerns about preventing future deaths.

Date 17 Feb 2015

56-day deadline 14 Apr 2015

Responses identified 0 of 1

Mental Health related deaths

Coroner's concerns

AI summary

Key action plans developed following a death, with a November 2014 completion date, remained largely unimplemented by the time of the inquest, raising concerns about preventing future deaths.

View full coroner's concerns

(The action plans to which refer below accompanied my copy of the Root Cause Analysis Investigation Report approved by Barnet; Enfield and Haringey Mental Health NHS Trust on 17 September 2014. The Report was prepared following the Trust's investigation into Mr. Erdogan's death. The first Action Plan (so headed) appeared at pages 19 to 21 of the Report The second, headed "Haringey CRHTT (SUI) Action Plan" , with pages numbered 1 to 4, appeared immediately after the first Action Plan. It is my understanding that both Action Plans were prepared with a view to ensuring that the recommendations set in the Report would be implemented:) (1) Although the first Action Plan set out six steps to be taken as Action in Response to recommendations" and, although the 'Date to be completed" for items to 5 was stated to be November 2014" there was, by the date of the inquest (over two months later) no evidence before me that any of those five steps had been completed: (2) Although the Haringey CRHTT (SUI) Action plan likewise set out nine steps to be taken (some of which corresponded closely with those set out in the first Action Plan) , and likewise set a "Date to be completed" of "November 2014" there was again no evidence before me at the inquest that_items the out very numbers 1, and 3 t0 9 had been completed: (3) The risk of further deaths not being prevented will not be diminished if all outstanding steps have not already been completed, and if they are not completed without avoidable delay:

Report sections

Investigation and inquest

On 18 June 2014,the senior coroner commenced an investigation into the death of Huseyin Hasan Erdogan, aged 26. The investigation concluded at end of the inquest on 9 February 2015_ The conclusion of the inquest was: Medical cause of death: 1a. Cerebral hypoxia; 1b. Hanging and 2. Psychosis and depression: Narrative conclusion summarised: Failure by the mental health practitioners of Barnet; Enfield and Haringey Mental Health NHS Trust to conduct; and to act upon; fully-informed assessment of the deceased's mental state, which contributed to his death, in that it resulted in no steps being taken by them to prevent his hanging_

Circumstances of the death

Mr: Erdogan hanged himself on 4 June 2014 and, on 13 June 2014, died of cerebral hypoxia, which resulted directly from the hanging:

Action should be taken

In my opinion action should be taken to prevent future deaths and believe your organisation has the power to take such action.

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Shared signals

Related inquiry recommendations

Report details

Reference: 2015-0066
Date of report: 17 February 2015
Coroner: John Taylor
Coroner area: London (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: 14 Apr 2015.

Sent to

Barnet Enfield and Haringey Mental Health NHS Trust

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.