Source · Prevention of Future Deaths
Graham Darby
Ref: 2014-0367
Date: 24 Jul 2014
Coroner: Gail Elliman
Area: London North
0 responses identified · 3 indexed addressees
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AI-generated concerns summaryA specific threat made by Mr Darby to take his own life if evicted, mentioning a knife and rope, was not sufficiently flagged by other agencies to his housing provider, Family Mosaic. This meant Family Mosaic was unaware of the direct threat when making decisions.
Date
24 Jul 2014
56-day deadline
18 Sep 2014 est.
estimated from the report date
Responses identified
0 of 3
Coroner's concerns
A specific threat made by Mr Darby to take his own life if evicted, mentioning a knife and rope, was not sufficiently flagged by other agencies to his housing provider, Family Mosaic. This meant Family Mosaic was unaware of the direct threat when making decisions.
View full coroner's concerns
That there were a number of agencies involved in both trying to assist Mr Darby and to deal with his anti-social behaviour (which led to the eviction). That although information was passed on generally between agencies and that communication was ongoing about Mr Darby, the evidence disclosed that one significant piece of information was not flagged up as it was not made sufficiently clear to Family Mosaic who were responsible for his housing and eviction. This was that the psychiatrist from ARC made a specific observation that Mr Darby had said that he had a knife and a rope in his property and would take his own life if evicted. The witness from Family Mosaic said that this particular piece of information was not passed on and that if it had been different actions may have been taken. Such direct threats should be flagged up in similar circumstances.
Report sections
Investigation and inquest
On 24 June 2013 I commenced an investigation into the death of Graham Darby, born on 18 July 1956. The investigation concluded at the end of the inquest on 31 October 2013. The conclusion of the inquest was that the medical cause of death was suspension by ligature and that his death was a suicide.
Circumstances of the death
I concluded that Graham Darby had a mental and behavioural disorder due to alcohol dependence and that the day after having been evicted from his home he was found dead at his home address having forcibly re-entered the property.
Similar PFD reports
Report details
- Reference
- 2014-0367
- Date of report
- 24 July 2014
- Coroner
- Gail Elliman
- Coroner area
- London North
Responses identified
Responses identified
0 of 3
3 responses not yet linked
Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 18 Sep 2014 (estimated from the report date).
Sent to
- East London NHS Foundation Trust
- Family Mosaic
- Hackney Alcohol Recovery Centre