Source · Prevention of Future Deaths

Rebecca Overy

Ref: 2014-0535 Date: 17 Dec 2014 Coroner: Stephanie Haskey Area: Nottinghamshire Responses identified: 0 / 1 View PDF

An immediate transfer, mandated by law, was detrimental to a young adult's mental health. This highlighted a critical service gap for secure mental health care for 18-24 year olds with complex needs.

Date 17 Dec 2014
56-day deadline 11 Feb 2015 est.
Responses identified 0 of 1
Other related deaths

Coroner's concerns

AI summary
An immediate transfer, mandated by law, was detrimental to a young adult's mental health. This highlighted a critical service gap for secure mental health care for 18-24 year olds with complex needs.
View full coroner's concerns
1.That the immediate transfer of Miss the day after her 18'h birthday was not in her best interests_ was detrimental to her mental health and occurred purely due to the operation of s 30 of the Health and Social Care whereby the commissioners were obliged to arrange an immediate transfer, and the clinicians to concur with it, lest they be in breach of the act That there is no provision for secure mental health care for young adults in the age range 18-24, with a clinical picture similar to Rebecca's_ day being Overy Act,

Report sections

Investigation and inquest
From 17th to 27th November2014 the death of Rebecca Louise Overy was the subject of an Article 2 Inquest. It was found that Miss Overy had died as a result of hypoxic brain injury as a result of asphyxia whilst in adult secure mental health detention. The jury returned a Narrative Conclusion:
Circumstances of the death
Miss Overy's fatal injury was self-inflicted, and occurred whist she remained on the adult admission ward. She had been transferred there from Child and Adolescent secure mental health detention the after her 18" birthday, without any prior visit to the adult intuition and without any plan for a gradual transition, given Miss Overy's particular circumstances, despite this proposed by her adolescent responsible clinician_
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
2014-0535
Date of report
17 December 2014
Coroner
Stephanie Haskey
Coroner area
Nottinghamshire

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: 11 Feb 2015 (estimated).

Sent to

Department of Health and Social Care

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