UK Inquiry Tracker

Brian Goodman

PFD Report All Responded Ref: 2019-0129A

Date of Report 17 April 2019

Coroner Sarah Bourke

Coroner Area London Inner (North)

Response Deadline est. 9 August 2019

Community health care and emergency services related deaths

Judiciary.uk Report PDF

All 1 response received · Deadline: 9 Aug 2019

Coroner's Concerns (AI summary)

A known ligature point in the patient's room was not addressed, and similar hazardous door closing mechanisms remain in use in other properties, despite a history of suicide attempts by hanging.

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(1) Mr Goodman expressed thoughts of hanging himself in and November 2018. He also had a history of attempting suicide by hanging: (2) Whilst Mr Goodman'$ wardrobe rail was recognised to be an obvious ligature point and removed in May 2018,no steps were taken to change the door closing mechanism in his room which could also be as a ligature point: (3) The same type of door closing mechanisms continue to be used in One Support properties: ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and believe you and your organisation have the power to take such action. May used

YOUR RESPONSE You are under a to respond to this report within 56 days ofthe date of this report, namely by 15 June 2019 I,the coroner, may extend the period_ Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed_ COPIES and PUBLICATION Ihave sent a copy of my report to the Chief Coroner and to the following Interested Persons: daughter) Iam also under a duty to send the Chief Coroner a copy of your response The Chief Coroner may publish either or both in a complete or redacted or summary form: He may send a copy of this report to any person who he believes may find it useful or of interest: You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. Sarah BourkeTH LOI Assistant Coroner 17 April 2019 duty CORON KM

Responses

One Housing Housing Association

17 Apr 2019

Action Planned
One Housing will work with their property services to explore alternative fire door closures in high-risk schemes and implement ASIST suicide intervention skills training for staff. (AI summary)

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Dear Sarah Bourke Regulation 28 Report to Prevent Future Deaths (Brian Goodman) We are in receipt of the report dated 17 April 2019 and apologise for the in responding as we did not receive the original correspondence. We note your concerns and confirm the following actions we are putting in place; The door closing mechanisms referred to continue to be widely used in care and support services, not only run by One Housing: These are in place on fire doors. We will work with our property services division to look at alternative closures for fire doors in our schemes where there is a higher risk of suicide. We are not in a position to be able to guarantee that all our supported housing schemes will be fully anti-ligature as we have to balance this with our responsibility as a landlord in terms of fire risk: We currently run Suicide Awareness Training 2 months for our staff. We are now putting in place running Applied Suicide Intervention Skills Training (ASIST) which is more advanced for a group of staff across our range of services_ Both points are actioned with immediate effect: