Marnie Hill: Prevention of future deaths report
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Date of report: 17/10/2023
Ref: 2023-0388
Deceased name: Marnie Hill
Coroner name: Rachael Griffin
Coroner Area: Dorset
Category: Suicide (from 2015)
This report is being sent to: Department of Health and Social Care
| REGULATION 28 REPORT TO PREVENT FUTURE DEATHS | |
|---|---|
| THIS REPORT IS BEING SENT TO: 1. The Rt Hon Steve Barclay MP, Secretary of State for Health and Social Care | |
| 1 | CORONER I am Rachael Clare Griffin, Senior Coroner, for the Coroner Area of Dorset |
| 2 | CORONER’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. |
| 3 | INVESTIGATION and INQUEST On the 18th May 2022, an investigation was commenced into the death of Marnie Emma Hill, born on the 14th April 1973. The investigation concluded at the end of the Inquest on the 6th October 2023. The Medical Cause of Death was: Ia Suffocation [REDACTED] & [REDACTED] overdose The conclusion of the Inquest was suicide. |
| 4 | CIRCUMSTANCES OF THE DEATH On the 15th May 2022 Marnie Emma Hill was found in a collapsed and unresponsive condition lying on the bed, in the bedroom at the property she was temporarily residing at, namely 40 Moorlands Road, West Moors, Ferndown. [REDACTED]. |
| 5 | CORONER’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. During the inquest evidence was heard that: i. There is no regulation of counsellors in England and Wales and this could lead to future deaths. ii. [REDACTED] is a private counsellor with 30 years’ experience who provided support to Marnie prior to her death. She confirmed that counselling is not a regulated professional and there are courses available at a cost of £29 for a 6 week course, after which a person can receive a diploma and call themselves a counsellor. There is no requirement for them to do further training or continual professional development. There are no rules or regulations about how counsellors should operate, for example how they keep and share records. iii. Information shared by an individual to a counsellor may disclose a risk of self harm or suicide, or harm to another and there is no requirement for a counsellor to report that information to any third party. iv. [REDACTED] gave evidence that the lack of regulation and licensing of counsellors could lead to a lot of damage being done to individuals seeking help and that this could present a risk to life as there is no regulation around informing medical professionals or others who can provided further support and care to the individual. v. Evidence was also given by [REDACTED] , one of the GPs who provided care to Marnie, that receipt of records from others such as counsellors, especially at the end of the counselling, would assist her in providing care to patients. 2. I have concerns with regard to the following: i. There is a risk of future deaths occurring due to the lack of regulation of the counselling profession. |
| 6 | ACTION SHOULD BE TAKEN In my opinion urgent action should be taken to prevent future deaths and I believe you and/or your organisation have the power to take such action. |
| 7 | OUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, 12th December 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. |
| 8 | COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: (1) [REDACTED] (2) [REDACTED] (3) [REDACTED] (4) NHS England (5) Dorset Healthcare NHS Foundation Trust (6) South West Ambulance Service NHS Foundation Trust (7) The Barcellos Family Practice (8) [REDACTED] I am also under a duty to send the Chief Coroner a copy of your response. I have also provided a copy of this to the British Association for Counselling and Psychotherapy for their awareness. 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. |
| 9 | 17th October 2023 Rachael C Griffin |