Gary Cooper: Prevention of future deaths report

Prevention of Future DeathsSuicide (from 2015)

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Date of report: 12/01/2023
Ref: 2023-0015
Deceased name: Gary Cooper
Coroner name: Robert Cohen
Coroner Area: Cumbria
Category: Suicide (from 2015)
This report is being sent to: Department for Culture Media and Sport and Department of Health and Social Care

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
 THIS REPORT IS BEING SENT TO: (1) The Secretary of State for Culture Media and Sport and (2) The Secretary of State for Health and Social Care CORONER
1CORONER I am Robert Cohen, HM Assistant Coroner for Cumbria
2CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www.legislation.gov.uk/uksi/2013/1629/part/7/made  
3INVESTIGATION and INQUEST On 6 July 2022 I commenced an investigation into the death of Gary Dennis COOPER. The investigation concluded at the end of the inquest . The conclusion of the inquest was   Suicide
4CIRCUMSTANCES OF THE DEATH Gary Cooper was 41 years old. He lived in Kendal, Cumbria. He suffered from depression and psychosis. On 3rd July 2022 Mr Cooper was found at home. He was unresponsive. An ambulance attended but resuscitation was not possible; Mr Cooper’s death was confirmed at 15:15. A post mortem examination has confirmed that Mr Cooper died as a result of having ingested
 
5CORONER’S CONCERNS
During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you.
The MATTERS OF CONCERN are as follows. –
1)
2)
6ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action.
7YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report,
namely by 9th March 2023. 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.
8COPIES and PUBLICATION
I have sent a copy of my report to the Chief Coroner and to Mr Cooper’s family.
I am 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.
12 January 2023
9Signature Robert Cohen HM Assistant Coroner for Cumbria