Source · Prevention of Future Deaths

Miriam Roach

Ref: 2026-0387 Date: 6 Apr 2026 Coroner: Guy Davies Area: Cornwall & Isles of Scilly 1 response identified · 1 indexed addressee View PDF

Response deadline: 25 November 2026 (estimated from the Judiciary.uk publication date).

Date 6 Apr 2026

56-day deadline 25 Nov 2026 est. estimated from the Judiciary.uk publication date

Responses identified 1 of 1

Coroner's concerns

Coroner’s Concerns (source excerpt)

(1) Regarding the aftercare or transition arrangements for those discharged from hospital to home with a moderate to high risk of self-harm and/or suicide following incidents of self-harm or suicide. (2) Specifically the obligations for putting in place contact arrangements for such patients.

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Responses

1 respondent

NHS Kernow Clinical Commissioning Group

PDF

Received

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Dear Mr Davies, Thank you for your regulation 28 report to prevent future deaths pertaining to Miriam Roach. In your report you identify two matters of concern and the action to be taken by NHS Kernow Clinical Commissioning Group (NHSK) as commissioners of mental health services as follows; A review of the aftercare or transition arrangements for those discharged from hospital to home with a moderate to high risk of self-harm and/or suicide following incidents of self-harm or suicide, including a review of the obligations for putting in place contact plans for such patients. Please find below NHS Kernow Clinical Commissioning group’s response to this action; A number of service areas are currently subject to transformation and enhancement. These areas include Psychiatric Liaison services working from the Royal Cornwall Hospital Trust (RCHT), transforming from its current hours of service of 08:00 to 22:00 to a 24 hour, 7 day a week service responding to people with a range of complex needs and will be compliant with the required national standard by 31st March 2019, in advance of the NHSE target date of 2020/21. In addition NHS Kernow and Cornwall Foundation Trust (CFT) have agreed to commence a formalised process to review a number of service specifications which will prioritise those currently subject to transformation. The review of aftercare and transition arrangements as you requested will be addressed within this as related to the delivery of more than one service. This action will be led by the Mental Health commissioning team. This action will commence over the summer and will be expected to be completed by December 2018. CFT’s progress will be reported monthly via the integrated assurance meeting hosted by NHS Kernow CCG with overall assurance reported to NHS Kernow CCG’s Quality and Performance Committee. ® 01726 627800 O kccg.contactus@nhs.net Head office: © www.kernowccg.nhs.uk Sedgemoor Centre, Priory Road, St Austell, Q /nhskernow Cornwall, PL25 5AS

[Page 2] NHS Kernow YEARS OF THE NHS 2018 Clinical Commissioning Group NHS Kernow recognises the value of sharing the learning from serious incidents to the wider health community. The quality team will share the learning and associated actions related to this incident with our partners in Devon, Somerset and Dorset via our Community of Practice and with NHS England and NHS Improvement through our Quality Network. If you require any further information or I can be of any further assistance please do not hesitate to contact me.

Report sections

Investigation and inquest

On 18th July 2017 I commenced an investigation into the death of Miriam Roach (DOB 28/03/1962 Aged 55). The investigation concluded at the end of the inquest on 29th March 2018.

The legal conclusion of the inquest was Suicide.

The four questions – who, when, where and how – were answered as follows. Miriam Roach died on 1st July 2017 at Lansdowne Flats, The Belyars, St Ives, Cornwall by hanging [REDACTED]

The medical cause of death was established on the evidence as hanging.

Circumstances of the death

Miriam Roach had a previous medical history of depression, anxiety and alcohol dependency. The history indicated that intoxication on occasion led to self-harm. Miriam had attended a number of detoxification programmes – in 2006, 2014, 2017.   Miriam had previously taken overdoses in July & August 2006, July 2008, and lastly 29th June 2017. Miriam had received support from drug and alcohol support service

Addaction in relation to alcohol addiction, on and off since 2013. The death of her mother and father at the end 2016 appears to have triggered an increase in alcohol consumption. Miriam attempted suicide on the 29th June 2017 and was admitted overnight at Royal Cornwall Hospital (RCHT). On the same day Miriam informed medical staff that she was disappointed she had not died and was found to have suicidal intentions.

The following day 30th June 2017, Miriam was assessed by the psychiatric team. The assessment recorded a moderate risk of self-harm when intoxicated. Miriam informed the team that she now regretted the overdose from the previous evening and indicated no plans to act on suicidal thoughts. Protective factors were identified. Miriam was found to have capacity and no grounds were identified for consideration of detention under the Mental Health Act.

Miriam was then discharged from RCHT on 30th June 2017 with a care plan which did not include a contact plan. There was no arrangement for Miriam to be contacted by support services or any health services following discharge.

The NICE guidance entitled ‘Transition between inpatient mental health settings and community or care home settings’ states patients discharged from specialist mental health services should be contacted within a week, and those thought to be at risk of suicide within 48 hours. The court heard that the NICE guidance did not apply in Miriam’s case because RCHT was not a mental health setting.

Action should be taken

namely a review of the aftercare or transition arrangements for those discharged from hospital to home with a moderate to high risk of self-harm and/or suicide following incidents of self-harm or suicide, including a review of the obligations for putting in place contact plans for such patients.

Copies sent to

[REDACTED], Drug Related Death Prevention Coordinator for Cornwall Drug and Alcohol Action Team

Similar PFD reports

Shared signals

Report details

Reference: 2026-0387
Date of report: 6 April 2026
Coroner: Guy Davies
Coroner area: Cornwall & Isles of Scilly

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: 25 Nov 2026 (estimated from the Judiciary.uk publication date).

Sent to

Chief Officer (Accountable Officer) NHS Kernow Clinical

Part of a series

2 reports

2018-0096 0 responses identified

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk.

Contains public sector information licensed under the Open Government Licence v3.0.