Nicholas Dymond: Prevention of future deaths report

Railway related deaths

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Date of report: 21/12/2023

Ref: 2023-0545

Deceased name: Nicholas Dymond

Coroner name: Alison Longhorn

Coroner Area: Exeter and Greater Devon

Category: Railway related deaths

This report is being sent to: Devon Partnership NHS Trust

[REDACTED] Devon Partnership NHS Trust Wonford House Dryden Road Exeter EX2 5AF
I am Alison Longhorn, Area Coroner for the coroner area of Exeter and Greater Devon.
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.
On 13 November 2018 an investigation was commenced into the death of Nicholas James Glavind Dymond. The investigation concluded at the end of the inquest on 19 June 2023. The conclusion of the inquest was suicide.

The cause of death was recorded as:
1a) Fatal injuries of head, neck, chest, right leg
1b) Railway accident
Nicholas Dymond had been an intermittent drug user for much of his adult life. In 2018 he began to suffer from paranoia and by October that year he had started to express thoughts of suicide – specifically of jumping in front of a train. His GP referred him to the Mental Health Crisis Team.   Following Nicholas’ arrest on 31st October 2018, a Mental Health Act Assessment was carried out. He was discharged and a taxi was arranged to take him home. On arrival of the taxi, Nicholas ran away. He was seen less than 3 hours later to step in front of a train at a local train station. He was pronounced deceased 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:
The inquest heard that independent doctors did not have access to the CareNotes and relied upon printed copies of extracts from the notes which the AMHP considered pertinent to the Mental Health Act Assessment. Training is now available for independent s.12 doctors which, once completed, allows them access to CareNotes, but this training is not a mandated condition of their inclusion on the list of approved s.12 doctors. There remains a risk that, should a Trust doctor not be available to conduct the assessment, an independent doctor with no access to the patient’s records would be called upon to conduct an assessment.

Several witnesses illustrated a lack of understanding of the concept of both a voluntary admission where a patient has undergone a Mental Health Act Assessment and of the ‘least restrictive option’. The opportunity for a patient to be admitted voluntarily for further assessment and treatment may therefore be missed.
In my opinion action should be taken to prevent future deaths and I believe that you and your organisation has 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 22 February 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.
I have sent a copy of my report to the Chief Coroner and to Nicholas Dymond’s Family.
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.
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.
921 December 2023
Alison Longhorn