UK Inquiry Tracker

Terry Latimer

PFD Report Historic (No Identified Response) Ref: 2017-0178

Date of Report 1 June 2017

Coroner Paul Kelly

Coroner Area North Lincolnshire and Grimsby

Response Deadline est. 29 September 2017

Community health care and emergency services related deaths Suicide (from 2015)

Judiciary.uk Report PDF

Coroner's Concerns (AI summary)

A safeguarding notice with a request for Mental Health Services referral was not actioned. There was a lack of clarity among staff on whether such notices required follow-up or were just for information.

View full coroner's concerns

The safeguarding notice was not acted upon either at all or appropriately. In particular a request accompanying the notice that the case be referred to Mental Health Services was not complied with. Evidence indicates lack of clarity in understanding whether the notice is just for information or should be followed up.

Sent To

North Lincolnshire Council

Response Status

Linked responses 0 of 1

56-Day Deadline 29 Sep 2017

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 2nd June 2016 I began an investigation into the death of Terry Stapleton Latimer who died on 27th May 2016 by hanging. The investigation concluded with an inquest on 25th May 2017

Circumstances of the Death

On 27th May 2016 the deceased was found dead by hanging at his home address. An inquest determined he died by suicide. The deceased received inpatient care in local psychiatric services between 18th April and 25th April 2016. On 15th May 2016 Police persuaded him to attend A&E at Scunthorpe General Hospital following safety concerns. The deceased did not wait to be seen.

A Safeguarding notification was generated by the attending Police Officer and submitted through usual procedures on 16th May 2016.

Action Should Be Taken

Namely a review with stakeholders (Police, A&E, mental health services) as to practices and procedures for safeguarding referral of mentally disordered persons known to be a threat to his or her own safety.