Naomi Sourbut
PFD Report
Historic (No Identified Response)
Coroner's Concerns (AI summary)
Recommendations from a 2017 root cause analysis report regarding suicidal ideation and protective factors for individuals expressing intent to self-harm were not clearly implemented.
View full coroner's concerns
_ (1) A rootcause analysis investigation was undertaken by_ the Devon Partnership Trust and that report was finalised on the 8th September 2017_ The report contained a number of identified lessons learned and recommendations; ten _in total see attached annexe), applicable to different teams within Devon Partnership Trust It was unclear at the Inquest as to whether or not these recommendations have been considered and acted upon by the teams to which they were directed particularly where clients have talked of suicidal ideation and identified the means with which to bring about their death: In my opinion action should be taken to prevent future deaths and believe you and your organisation has to take such action to confir the recommendations in the root cause analysis report File No: 2017/10523 NON ANON RCA JHNS 18.9.17 having been considered and implemented, (2) In addition where an individual has indicated an intent to cause themselves harm and have advised clinicians they have access to the means to cause that harm then protective factors should be 'in place to help reduce the risk of the individual harming themselves in the way they have indicated or otherwise_
Sent To
- Devon Partnership Trust
Response Status
Linked responses
0 of 1
56-Day Deadline
13 Feb 2018
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 23rd May 2017 commenced an investigation into the death of Naomi Clare SOURBUT aged 26 years; The investigation concluded at the end of the inquest on 19h December 2017. The medical cause of death was: Ia Hypoxic Brain Injury 1b Medication Overdose (most probably Venlafaxine) A narrative conclusion was given as follows: Naomi Clare Sourbut died from Hypoxic Brain Injury following a self-administered overdose of medication, most probably Venlafaxine drug prescribed to treat her depression.
Circumstances of the Death
Ms Sourbut had a history of anxiety and depression. In her late teens she self-harmed and this continued, she also became bulimic. She engaged with Primary Care practitioners and Secondary Care in the form of the Community Mental health team: She engaged with that team between May and December 2016 and re-engaged in March 2017 by referral from her GP_ She was prescribed the anti-depressant Venlafaxine. Ms Sourbut had met with her Community Mental Health practitioner on the 27th March 2017,, discussed her condition and this person had previously been her care CO-ordinator; A new care co-ordinator was to be appointed with effect from the 3rd April 2017 . There was a review of her medication and recommendations were sent to her
Action Should Be Taken
In my opinion action should be taken to prevent future deaths and believe you [ANDIOR your organisation] have the power to take such action.
Inquest Conclusion
Naomi Clare Sourbut died from Hypoxic Brain Injury following a self-administered overdose of medication, most probably Venlafaxine drug prescribed to treat her depression.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.