Source · Prevention of Future Deaths

Michaela Christoforou

Ref: 2014-0285 Date: 25 May 2014 Coroner: Andrew Walker Area: London (North) Responses identified: 1 / 1 View PDF

All staff at the unit did not carry ligature cutters, posing a significant risk in preventing self-harm incidents.

Date 25 May 2014
56-day deadline 20 Jul 2014 est.
Responses identified 1 of 1
Care Home Health related deaths

Coroner's concerns

AI summary
All staff at the unit did not carry ligature cutters, posing a significant risk in preventing self-harm incidents.
View full coroner's concerns
That all staff at the unit did not carry with them a ligature cutter

Responses

1 respondent
Response
PDF
Action Planned

Care UK has now located nine sets of ligature cutters throughout Rhodes Farm. Clinical staff will carry ligature cutters for a six month trial period commencing in September 2014 and a protocol/procedure is being developed that covers all aspects concerned with the carrying and management of ligature cutters. (AI summary)

View full response
Dear Sir, We refer to the enclosed Regulation 28 report which was issued following the Inquest into the death of Michaela Christoforou: After considering your report very carefully Care UK wishes to inform you that we have taken andlor intend to take the following actions: There are now nine sets of ligature cutters located throughout Rhodes Farm (three on each floor):
2. Clinical staff will carry ligature cutters for a six month trial period commencing in September 2014_ 3_ A protocollprocedure is developed that covers all aspects concerned with the carrying and management of ligature cutters: Care UK is working with a specialist knife company with the intention of developing knife that is both discrete and tamper proof:
5. Care UK is liaising with NHS England, our customer; regarding this issue_ trust that the above action is sufficient to meet the concerns that you have expressed. If there is any further information you require please do not hesitate to contact me

Report sections

Investigation and inquest
On the 24th April 2013 opened an inquest toughing the death of Michaela Jade Christoforou 17 years old . The inquest concluded on the 28"h April 2014. The conclusion of the inquest was suicide, the medical case of death was Ia Hypoxic Brain Injury, 1b Hanging and Ic anorexia nervosa and depression
Circumstances of the death
Michaela was 17 years old at the time of her death and a patient at Rhodes Farm Hospital in North London. Michaela was suffering with an eating disorder and a risk of suicide and in the period leading up to her death was not able to leave hospital without the consent of the medical staff looking after her; In January 2013, whilst at home, following an overdose and an attempt at hanging herself;, Michaela returned initially to Forest House Adolescent Unit; bedded unit for young people between the ages of 12 to 18 and then on the 18th January to Rhodes Farm Hospital, a 24 bedded specialist child and adolescent eating disorder service. On the 24th January 2013 Michaela was detained under section 3 of the Mental Health Act 1983 and had to stay in _hospital unless her doctors_ and

Her Majesty's Coroner for the Northern District of Greater London (Harrow, Brent; Barnet; Haringey and Enfield) allowed her to leave the hospital. On the 14u April 2013 Michaela was in hospital when found with bunting around her neck suspended from a metal locker in a classroom at the hospital: Michaela was taken to St Mary's Hospital Paddington where she died sadly on the 17ih April 2013.
Action should be taken
In my opinion action should be taken to prevent future deaths and believe you [ANDIOR your organisation] have the power to take such action_

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Report details

Reference
2014-0285
Date of report
25 May 2014
Coroner
Andrew Walker
Coroner area
London (North)

Responses identified

Responses identified 1 of 1
All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 20 Jul 2014 (estimated).

Sent to

Care UK

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