Julie Rose
PFD Report
Unknown
No published response · Over 2 years old
Response Status
Responses
0
56-Day Deadline
8 Feb 2016
Over 2 years old — no identified published response
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Coroner's Concerns
In the circumstances it is my statutory to report to you: Whilst heard evidence at the inquest of the considerable efforts the Trust has made to reflect on the circumstances of Miss Rose's death and mitigate the risk of similar deaths occurring, it is my opinion that there remain matters of concern: These residual _ (1) Although the Trust's Unable to Make Contact Protocol ("the Protocol") has been reviewed since Miss Rose'$ death, am concerned that it is insufficiently clear as to when Crisis Resolution Home Treatment Team members should request a police welfare check in respect of patients who have been identified as 'Red' for the purposes of the Trust'$ R A G Rating System_ In particular , am concerned the Protocol does not specifically stipulate circumstances where a request for a welfare check is mandatory (for example, after a certain period of time has elapsed since contact was last made, and or after a certain number of attempts at contact and or after attempts at telephone contact and a home visit have both been unsuccessful); (2) In the course of the hearing, heard evidence that the Protocol has been 'reinforced' across the Crisis Resolution Home Treatment Team. Notwithstanding this, a shift co-ordinator who gave evidence was clearly not conversant with the Protocol, raising questions as to the adequacy of the steps taken by the Trust to date in this respect.
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:
Report Sections
Investigation and Inquest
On 29th April 2015,an inquest was opened into the death of Julie Margaret Rose who was found dead on 26th April 2015, 54 years. held a Pre-Inquest Review on Znd September 2015,and conducted an inquest on 9th December 2015 at Folkestone Magistrates Court The conclusion of the inquest was suicide, the medical cause of death suspension_
Circumstances of the Death
On 24th April 2015, Miss Rose (who was well-known to the Trust's Community Mental Health and South East Kent Crisis Resolution Home Treatment Team as a result of long-standing depression, anxiety and Obsessive Compulsive Disorder) was brought to St Martin'$ Hospital, Canterbury by police under 5136 Mental Health Act following a concern that she intended to take her own life. Following assessment by an Approved Mental Health Professional, Consultant Psychiatrist and independent (s12) doctor; Miss Rose was discharged from 5136 with a plan in place for support at home by the Crisis Resolution Home Treatment Team and a medication review. On 2Sth April 2015, Miss Rose was visited at home by two members of the Crisis Resolution Home Treatment Team who noted her to be Iow in mood: Miss Rose agreed to undertake tasks and techniques intended to improve her state of mind: At approximately 14.50,a supportive telephone call was made to Miss Rose who reported she felt suicidal. The specialist support worker who spoke with Miss Rose again made suggestions as to steps she could take to improve her mood Further attempts to contact Miss Rose by telephone at 17.00, 18.00 and 22.30 were unsuccessful, as was an attempted home visit at around 09.25 on 26th April 2015 Although at least one team member expressed concerns that it was unusualnot to be aged being able to contact Miss Rose, no attempts were made to contact family members who also supported her: Additional attempts were made without success to contact Miss Rose by telephone, and following a further attempted home visit at around 16.00 (over 24 hours after Trust staff had managed to make any contact with Miss Rose), Kent Police was contacted and a welfare check requested. Officers forced entry to Miss Rose's home, where she was found dead.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.