Source · Prevention of Future Deaths
Huseyin Erdogan
Ref: 2015-0066
Date: 17 Feb 2015
Coroner: John Taylor
Area: London (North)
0 responses identified · 1 indexed addressee
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AI-generated concerns summaryThe coroner noted a lack of evidence that steps outlined in two action plans, created in response to Mr. Erdogan's death, had been completed by the stated deadlines prior to the inquest. This delay in implementation raises concerns about preventing future deaths.
Date
17 Feb 2015
56-day deadline
14 Apr 2015
stated in the report
Responses identified
0 of 1
Coroner's concerns
The coroner noted a lack of evidence that steps outlined in two action plans, created in response to Mr. Erdogan's death, had been completed by the stated deadlines prior to the inquest. This delay in implementation raises 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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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 (stated in the report).
Sent to
- Barnet Enfield and Haringey Mental Health NHS Trust