UK Inquiry Tracker

Kevin Paul Sutton

PFD Report Historic (No Identified Response) Ref: 2013-0375

Date of Report 14 November 2013

Coroner Kevin Paul Sutton

Coroner Area West Somerset

Response Deadline est. 9 January 2014

Hospital Death (Clinical Procedures and medical management) related deaths

Judiciary.uk Report PDF

Coroner's Concerns (AI summary)

The Trust failed to prepare essential care plans for patients discharged from its wards to other establishments, risking inadequate ongoing care.

View full coroner's concerns

During the course of the inquest I formed the opinion that there was a risk that future deaths could occur unless care plans were prepared for any patient leaving wards under the control of the Somerset Partnership Foundation Trust, when they were being discharged to another establishment.

Failure by the Trust to provide care plans.

Sent To

Somerset Partnership NHS Foundation Trust

Response Status

Linked responses 0 of 1

56-Day Deadline 9 Jan 2014

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 3rd September 2012, I commenced an investigation into the death of Kevin Paul SUTTON deceased aged 57 years. The investigation concluded at the end of the Inquest on 14 November 2013. The Conclusion of the Inquest was that the deceased had met his death by suicide and the cause of death was: 1a Asphyxia
2. Huntingdon’s Disease

Circumstances of the Death

The deceased had first been referred to the Somerset Partnership NHS Foundation Trust towards the beginning of this century but the first entry recorded in your Trust records is in April 2005.

Over the ensuing years he was seen on a number of occasions by a Consultant Psychiatrist from your Trust due to his continuing depression but was then thought to be low suicidal risk as a result of his Huntingdon’s disease.

The deceased was later admitted to Rydon Ward, Cheddon Road , Taunton where he was discharged on the 19 June 2012 to the Willows at Bridgwater but was admitted to Musgrove Park Hospital on the 26 June as he was not eating or drinking.

On the 11 July 2012 he was discharged from Musgrove Park Hospital to Halcon House, Huish Close, Taunton, premises belonging to Somerset Care Limited from where on the 3 September he would take his own life.

During the Inquest evidence was given by the manager of Halcon House that no care plan had been prepared, and as a consequence they were not made aware of the real suicidal risk that they faced with the deceased.

Action Should Be Taken

That there should be brought in rules making it obligatory for care plans to be prepared and lodged with any other establishment to which a patient is discharged.