“On 28 August Ms Dehaney-Perkins was agitated and distressed on return to the ward from…”

The coroner’s concerns

– (1) On 28 August Ms Dehaney-Perkins was agitated and distressed on return to the ward from leave and had consumed alcohol that was known to increase her risk of self-harm. . Staff found Ms DehaneyPerkins and removed the ligature. a. Ms Dehaney-Perkins was admitted to a room with an assisted bathroom (this was not a requirement for her) with a fault in the antiligature safety mechanism meant that the safety feature could not be implemented. b. There was no risk assessment about the suitability of this room for Ms Dehaney-Perkins a patient with a self-harming history at the time of the admission. c. The fixed-point ligature was not appropriately updated in the risk assessment and was not discussed at a discharge planning meeting. d. The Trust Datix Report was incomplete (2) Medication was appropriately withheld on 28 August when Ms DehaneyPerkins returned to the ward intoxicated due to potential interaction with alcohol that can cause increased sedation, (3) arrhythmia and fatality. a. This risk of consuming alcohol with her specific medication was not 2 discussed with the Ms Dehaney-Perkins or family. b. Not all incidents of consumption of alcohol on return from leave were recorded and risk assessments were not updated. c. Ms Dehaney-Perkins had agreed to mitigations of medication management by her family that were not recorded on the care plan on discharge on 2 September. Ms Dehaney-Perkins demanded control of her medication on 4 September against concerns of her family who were forced to return medication. (4) The Home First Treatment Team attended a scheduled appointment on 4 September and Ms Dehaney-Perkins appeared stable and updated the risk assessment that the risk of self-harm remained significant when alcohol was consumed. No action was taken following a call raising some queries and concerns from family that evening that Ms DehaneyPerkins had left her home with her medication.

An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.

Source

judiciary.uk, Prevention of Future Deaths reports, 2024-0059

Added to Minute Book

8 Oct 2026

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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0