Jacqueline Cobain: Prevention of future deaths report

Railway related deathsSuicide (from 2015)

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Date of report: 25/03/2024

Ref: 2024-0163

Deceased name: Jacqueline Cobain

Coroner name: Michelle Haste

Coroner Area: Inner South London

Category: Railway related deaths | Suicide (from 2015)

This report is being sent to: South London and Maudsley NHS Foundation Trust

 [REDACTED] Chief Executive, South London and Maudsley NHS Foundation Trust, Maudsley Hospital, Denmark Hill, London, SE5 8AZ
I am Michelle Haste, Assistant Coroner for Inner London South
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/ http://www.legislation.gov.uk/uksi/2013/1629/part/7/made
On the 16 September 2021 an investigation into the death of Jacqueline Anne Cobain commenced, aged 60 years. The investigation concluded at the end of the final day of the inquest on 15 March 2024. The conclusion of the inquest was a short form conclusion of suicide.


Jacqueline Anne Cobain had a past medical history of anxiety and depression, as well as alcohol dependence. She was consulting with her P in relation to these issues and was taking antidepressants. She had also contacted mental health services, although she had cancelled the scheduled appointment and the rescheduled appointment was not until 16 September 2021, however she had submitted her responses to a questionnaire shortly after cancelling her appointment which had included some concerning responses. This questionnaire was not reviewed upon receipt. She had taken an overdose some years before at a time of great stress in her working life and her family believed this was not an attempt to take her life, but rather a consequence of stress, desperation of her work situation and insomnia. During the afternoon of 11 September 2021, she deliberately jumped in front of moving train at Vauxhall London Underground station, London. Her family indicated that she seemed stable, and they were less concerned about her than they had been for some time. She suffered multiple injuries and died at the scene.
During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you.
The MATTERS OF CONCERN are as follows:
When Mrs Cobain cancelled her appointment scheduled for Monday 6 September 2021 by email on Saturday 4 September 2021, the system nevertheless generated

an automatic questionnaire which is normally is sent 24 hours prior to a scheduled assessment appointment. The system had not recognised that Mrs Cobain had cancelled her appointment. She completed the questionnaire.
Mrs Cobain’s responses to the questionnaire contained what were accepted to be concerning responses.
Due to the cancellation the questionnaire was not reviewed by a clinician until after Mrs Cobain’s sad death.

Changes have been made to the protocols around cancellation, and language has been added to the assessment template.

However, there is no system or protocol to alert a clinician to review concerning responses and to consider appropriate next steps, where (outside the usual protocol and time frame of submission and review within 24 hours of the assessment appointment) the patient has completed the questionnaire, and for whatever reason, the assessment appointment with the clinician is not for a period of several days/weeks as was the case in Mrs Cobain’s case.
In my opinion action should be taken to prevent future deaths and I believe you [AND/OR your organisation] have the power to take such action.
You are under a duty to respond to this report within 56 days of the date of this report, namely by 20 May 2024 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.
I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: the family of Mrs Cobain, I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it.
I may also send a copy of your response to any other person who I believe may find it useful or of interest. 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.
925nd March 2024