Max Turbutt
PFD Report
All Responded
Ref: 2022-0327
All 1 response received
· Deadline: 13 Dec 2022
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56-Day Deadline
13 Dec 2022
All responses received
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Source: Courts and Tribunals Judiciary
Coroner’s Concerns
Max’s father told me at inquest that in March and April 2022, Max tried to contact his personal advisor at the 18+ Service at Thistley Hill in Dover on several occasions over a number of weeks, but found her phone always to be switched off. There was no redirect and no out of office on her email.
Max’s father also tried to call her, with the same result. Just over a week after Max’s death, his family received a letter addressed to him from Kent Social Services, explaining that his social worker was off sick. A crisis number was given and Mr Turbutt called it, but it was simply an answerphone.
This arrangement does not seem adequate for a vulnerable person in need.
Max’s father also tried to call her, with the same result. Just over a week after Max’s death, his family received a letter addressed to him from Kent Social Services, explaining that his social worker was off sick. A crisis number was given and Mr Turbutt called it, but it was simply an answerphone.
This arrangement does not seem adequate for a vulnerable person in need.
Responses
Response received
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Dear Coroner Hassell Prevention of Future Deaths Report – Max Turbutt (died 25.04.22) I have been asked to write substantively to you given my role as the Council’s Monitoring Officer.
I would like to start by offering the Council’s apologies for the delay in providing a response in reply to the correspondence issued under Regulation 28 The Coroners (Investigation) Regulations 2013 regarding the death of Max Turbutt, who was a young adult being supported by the Kent County Council 18+ Care Leavers Service.
Having reviewed that letter, you expressed concerns that during March and April 2022 Max tried to contact his Personal Advisor on several occasions over a number of weeks, but the phone was switched off; that his father also tried, with the same result, with no redirect or out of office on email. The crisis duty number was tried and went to a recorded message, asking the caller to leave a message. Max very sadly took his own life on the 25th of April 2022.
In providing this response, I have liaised with our Corporate Director for Children, Young People and Education who instructed the Team Manager for the South East Team of KCC’s 18+ Care Leavers Service to investigate your concerns. As a result of those investigations, I am able to provide the following information to you.
Max and his Personal Advisor (PA) spoke on 3rd, 7th and 14th of March 2022 and our contact records show that areas discussed were Max’s wellbeing, his housing options and support with his claim for Universal Credit. On 16th March, Max was visited in person by his PA and he said that he was feeling more settled being back in Folkestone and received advice on his housing options.
During the home visit on 16th March 2022, the PA updated Max’s Pathway Plan, also discussing this with their line manager during supervision. The following is taken from Max’s case file:
“During the Home Visit it is recorded that Max seemed more settled with his mental health by being back in Folkestone. Max has said that he has not heard from Folkestone council in regard to moving on. It was recommended that he get in contact with Folkestone council and start looking for accommodation, but he does not wish to do this. Max has said that he is managing at home and his relationship with his parents is ok at the moment. Max is still taking anti-depressants and his dose is being slowly increased. Max is focusing on his mental health and is not looking at getting a job. Max is still registered with the GP surgery in Blackheath. It has been recommended that he register with a local GP, but this is not something Max wishes to do at this time. Max's Dad is collecting prescriptions from London.”
As a follow up to this visit, the PA contacted Max a few days later and supported him to complete his Universal Credit claim.
On 8th April 2022 there was a telephone call between Max and his PA, where they advised Max, he should consider changing his GP surgery to Folkestone now he was back living in Kent.
On 12th April 2022, the PA sent a text to Max, advising they would be going on holiday soon and reminding him of the duty number to phone if he required support in their absence. The PA returned to work on 19th April 2022 but was unfortunately taken unwell which resulted in them going off from work on sick leave.
On the 29th April it became clear that the PA’s sickness was ongoing and would be longer term and as such, the Team Manager wrote to all the allocated young people to advise of this and in the letter provided Duty contact details.
Max’s PA went off work officially on sick leave on the 20th April 2022 and there were only 3 working days after this time, before Max’s tragic death. I am advised that the Council was aware that Max had fluctuating mental health issues and had sought to support him intensively the previous year when I am advised Max was very unwell. Sadly, during their communications with Max, the PA had not seen any indications during March or early April 2022 to indicate that his mental health was deteriorating. The PA was advised by Max that he was in regular touch with his GP surgery and had family locally who were supporting him to collect his medication.
The number provided to Max on 12th April 2022 was the 18+ Care Leavers Service Duty number. Duty calls are initially answered with the support of our Business Support Team and a number of Personal Advisors are available on each working day, during office hours, to respond to phone calls and provide emergency support to our 2,000 Kent young adults who are care leavers. At times of exceptional demand, if the call cannot be answered, it goes to an answer phone, and our Duty workers will ring people back the same day. If outside of office hours, Kent County Council also has an
Out of Hours Service to support with emergencies that cannot wait until the next working day. We have no record of a message being left by Max or his father but are happy to further investigate any additional details.
In direct response to the concerns you raised, when a tragic event happens, our service reviews any learning and on investigation of the concerns raised, whilst there was only a very short period of time between the Personal Advisor going off unwell and Max’s death, the service has made the following changes:
• Young adults will be advised immediately if their allocated Personal Advisor is off longer-term sick and provided with the name of the Team Manager, alongside the Duty contact number.
• The Team Manager will ask the relevant staff member to add a voice message to their mobile phone advising of who to contact in their absence.
• The Team Manager will ensure an Out of Office reply is added to the staff members email account if they are to be off on a longer-term basis.
Kent County Council send our condolences to Max’s family for their sad loss. I am also advised that Max’s suicide has been very upsetting to the service, and particularly his Personal Advisor, who from the regular communication they had with Max, had built a good relationship with him.
We hope this information answers your concerns, but please do not hesitate to contact me if I can be of any further assistance.
I would like to start by offering the Council’s apologies for the delay in providing a response in reply to the correspondence issued under Regulation 28 The Coroners (Investigation) Regulations 2013 regarding the death of Max Turbutt, who was a young adult being supported by the Kent County Council 18+ Care Leavers Service.
Having reviewed that letter, you expressed concerns that during March and April 2022 Max tried to contact his Personal Advisor on several occasions over a number of weeks, but the phone was switched off; that his father also tried, with the same result, with no redirect or out of office on email. The crisis duty number was tried and went to a recorded message, asking the caller to leave a message. Max very sadly took his own life on the 25th of April 2022.
In providing this response, I have liaised with our Corporate Director for Children, Young People and Education who instructed the Team Manager for the South East Team of KCC’s 18+ Care Leavers Service to investigate your concerns. As a result of those investigations, I am able to provide the following information to you.
Max and his Personal Advisor (PA) spoke on 3rd, 7th and 14th of March 2022 and our contact records show that areas discussed were Max’s wellbeing, his housing options and support with his claim for Universal Credit. On 16th March, Max was visited in person by his PA and he said that he was feeling more settled being back in Folkestone and received advice on his housing options.
During the home visit on 16th March 2022, the PA updated Max’s Pathway Plan, also discussing this with their line manager during supervision. The following is taken from Max’s case file:
“During the Home Visit it is recorded that Max seemed more settled with his mental health by being back in Folkestone. Max has said that he has not heard from Folkestone council in regard to moving on. It was recommended that he get in contact with Folkestone council and start looking for accommodation, but he does not wish to do this. Max has said that he is managing at home and his relationship with his parents is ok at the moment. Max is still taking anti-depressants and his dose is being slowly increased. Max is focusing on his mental health and is not looking at getting a job. Max is still registered with the GP surgery in Blackheath. It has been recommended that he register with a local GP, but this is not something Max wishes to do at this time. Max's Dad is collecting prescriptions from London.”
As a follow up to this visit, the PA contacted Max a few days later and supported him to complete his Universal Credit claim.
On 8th April 2022 there was a telephone call between Max and his PA, where they advised Max, he should consider changing his GP surgery to Folkestone now he was back living in Kent.
On 12th April 2022, the PA sent a text to Max, advising they would be going on holiday soon and reminding him of the duty number to phone if he required support in their absence. The PA returned to work on 19th April 2022 but was unfortunately taken unwell which resulted in them going off from work on sick leave.
On the 29th April it became clear that the PA’s sickness was ongoing and would be longer term and as such, the Team Manager wrote to all the allocated young people to advise of this and in the letter provided Duty contact details.
Max’s PA went off work officially on sick leave on the 20th April 2022 and there were only 3 working days after this time, before Max’s tragic death. I am advised that the Council was aware that Max had fluctuating mental health issues and had sought to support him intensively the previous year when I am advised Max was very unwell. Sadly, during their communications with Max, the PA had not seen any indications during March or early April 2022 to indicate that his mental health was deteriorating. The PA was advised by Max that he was in regular touch with his GP surgery and had family locally who were supporting him to collect his medication.
The number provided to Max on 12th April 2022 was the 18+ Care Leavers Service Duty number. Duty calls are initially answered with the support of our Business Support Team and a number of Personal Advisors are available on each working day, during office hours, to respond to phone calls and provide emergency support to our 2,000 Kent young adults who are care leavers. At times of exceptional demand, if the call cannot be answered, it goes to an answer phone, and our Duty workers will ring people back the same day. If outside of office hours, Kent County Council also has an
Out of Hours Service to support with emergencies that cannot wait until the next working day. We have no record of a message being left by Max or his father but are happy to further investigate any additional details.
In direct response to the concerns you raised, when a tragic event happens, our service reviews any learning and on investigation of the concerns raised, whilst there was only a very short period of time between the Personal Advisor going off unwell and Max’s death, the service has made the following changes:
• Young adults will be advised immediately if their allocated Personal Advisor is off longer-term sick and provided with the name of the Team Manager, alongside the Duty contact number.
• The Team Manager will ask the relevant staff member to add a voice message to their mobile phone advising of who to contact in their absence.
• The Team Manager will ensure an Out of Office reply is added to the staff members email account if they are to be off on a longer-term basis.
Kent County Council send our condolences to Max’s family for their sad loss. I am also advised that Max’s suicide has been very upsetting to the service, and particularly his Personal Advisor, who from the regular communication they had with Max, had built a good relationship with him.
We hope this information answers your concerns, but please do not hesitate to contact me if I can be of any further assistance.
Report Sections
Investigation and Inquest
On 3 May 2022, one of my assistant coroners, Sarah Bourke, commenced an investigation into the death of Max Turbutt, aged 21 years. The investigation concluded at the end of the inquest earlier today. I made a determination of death by suicide. The medical cause of death was hanging.
Circumstances of the Death
Max had suffered mental ill health for a number of years. He had been accommodated under Section 20 of the Children Act and supported by Kent County Council as a Child in Care, then as a Care Leaver by the 18 Plus Service under Section 23c of the Children Act.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.