August 13, 2024

Martyn Stringer: Prevention of Future Deaths Report

Suicide (from 2015)

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Date of report: 07/08/2024

Ref: 2024-0448

Deceased name: Martyn Stringer

Coroner name: Nicholas Graham

Coroner Area: Oxfordshire

Category: Suicide (from 2015)

This report is being sent to: NHS England

	REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
	THIS REPORT IS BEING SENT TO: NHS England
1	CORONER I am Nicholas Graham, HM Area Coroner, for the coroner area of Oxfordshire.
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 5 April 2023 an Inquest was opened into the death of Martyn Harvey Stringer who died on the 29 March 2023. On the 25 July 2024 I concluded an Inquest into his death at the end of a 3-day hearing.
4	CIRCUMSTANCES OF THE DEATH The immediate circumstances are that: On 24 March 2023, Martyn was detained by police in Sussex after being found at [REDACTED] where he had ostensibly gone to take his own life. He was taken to Eastbourne District General Hospital. There he was assessed and deemed liable for detention under Section 2 of the Mental Health Act. However, there were no available mental health beds nationally and a suitable placement could not be found for him. Having been at the hospital since Friday evening, he contacted family members on Sunday, 26 March who collected him and brought him back to his home in Oxfordshire. On 27 March 2023, Martyn left his home and stepped in front of a lorry on the A4074. Witnesses described his actions as deliberate. The medical cause of death was determined following a post-mortem examination to be multi-organ failure and polytrauma resulting from a road traffic collision.
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 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. – As you will note from the Conclusion, an application for compulsory detention for Martyn could not be completed due to the unavailability of beds despite extensive searches nationally. My findings were that: ‘It is the case that a Health Based Place of Safety bed did become available but a decision was taken that due to anticipated demand for potential patients not to offer this to Martyn.’ And also that: ‘in my view highly likely that Martyn would have benefitted from a further admission to hospital – as he had previously – and he would have prevented from further relapse and ultimately taking the actions he did on the morning of the 27 March.’ I heard evidence from experience mental health professionals that the lack of beds for those requiring detention under the Mental Health Act was a frequent occurrence. In my view, you should consider a review of sufficiency of provision for suitable placements for those requiring compulsory treatment.
6	ACTION SHOULD BE TAKEN In my opinion, action should be taken to prevent future deaths, and the coroner believes that your organisations have the power to take such action.
7	YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 02 October 2024. I, the Area 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 this report to: The family of Mr Stringer Oxfordshire ICB East Sussex ICB 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.
9	07 August 2024 Mr N Graham HM Senior Coroner