Steven Regoli
PFD Report
Historic (No Identified Response)
Ref: 2021-0273
Coroner's Concerns (AI summary)
Inadequate systems existed for providing in-depth mental health support to patients with anxiety and non-engagement issues, leaving families as the sole caregivers and preventing necessary intervention.
View full coroner's concerns
In the 7 day report it set out numerous opportunities for Steven and his family to have more appropriate help to include inpatient stay for Steven given his history of overdoses and his worsening anxiety and depression. He had spoken about taking himself down to the railway line on other occasions as he used to work near there. Steven, due to his anxiety and with COVID restrictions was unable to engage but he struggled engaging with people before these restrictions.
During the inquest, there were clear signs that Steven needed more in depth help as did his family, but due to him not engaging, which was a major part of his symptoms he was never given the pathway or help he needed and there were no systems in place for this to happen. There needs to be systems in place where people who do not engage are not left with family only to care for them.
During the inquest, there were clear signs that Steven needed more in depth help as did his family, but due to him not engaging, which was a major part of his symptoms he was never given the pathway or help he needed and there were no systems in place for this to happen. There needs to be systems in place where people who do not engage are not left with family only to care for them.
Sent To
- Essex Partnership University NHS Foundation Trust
- NHS England
Response Status
Linked responses
0 of 2
56-Day Deadline
12 Oct 2021
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On 5th August 2021 I commenced and concluded an inquest into the death of Steven Antonio Regoli
Circumstances of the Death
Steven Antonio Regoli died on the 26th June 2020 died at a Lineside location adjacent to Gipsy Lane due to Multiple Injuries following a collision with a train, with underlying Adjustment Disorder, Mixed Anxiety and Depressive Disorder. He was known to EPUT
At approx. 11.20 hours on the 26th June 2020 the driver of the Cambs North to Liverpool Street was coming around the track curve, when he saw a man stood under the bridge next to Gypsy Lane. As soon as he saw the train, this male pushed off the wall and headed into the path of the train. The driver was travelling at 70 mph and was unable to stop. Mr Regoli was identified by his fingerprints. EPUT prepared a 7-day report, which was being used during the COVID Pandemic. This report set out the detail of the issues that Steven Regoli had, he was predominantly living with his elderly parents who had consistently in evidence at the inquest said that they tried to get inpatient care for their son as they were struggling to cope, describing having to sleep by the front door to stop him leaving, where he would then take illicit drugs and overdose. The report set out that he was admitted to Peter Bruff Ward following an overdose and was discharged 7 days later and within 3 days had taken tablets, following this and the next day it was determined that he should be discharged back to his mother’s address.
On the 18th June 2020-8 days before Steven died, he told his Care Coordinator he felt like ending his own, which he then subsequently did.
At approx. 11.20 hours on the 26th June 2020 the driver of the Cambs North to Liverpool Street was coming around the track curve, when he saw a man stood under the bridge next to Gypsy Lane. As soon as he saw the train, this male pushed off the wall and headed into the path of the train. The driver was travelling at 70 mph and was unable to stop. Mr Regoli was identified by his fingerprints. EPUT prepared a 7-day report, which was being used during the COVID Pandemic. This report set out the detail of the issues that Steven Regoli had, he was predominantly living with his elderly parents who had consistently in evidence at the inquest said that they tried to get inpatient care for their son as they were struggling to cope, describing having to sleep by the front door to stop him leaving, where he would then take illicit drugs and overdose. The report set out that he was admitted to Peter Bruff Ward following an overdose and was discharged 7 days later and within 3 days had taken tablets, following this and the next day it was determined that he should be discharged back to his mother’s address.
On the 18th June 2020-8 days before Steven died, he told his Care Coordinator he felt like ending his own, which he then subsequently did.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.