Nicola Lacey: Prevention of future deaths report

Suicide (from 2015)

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Date of report: 26/06/2024

Ref: 2024-0340

Deceased name: Nicola Lacey

Coroner name: Hugh Gregory

Coroner Area: Herefordshire

Category: Suicide (from 2015)

This report is being sent to: Herefordshire and Worcestershire Health and Care NHS Trust.

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO: Robert Mackie, Chief Executive, Herefordshire and Worcestershire Health and Care NHS Trust.
1CORONER  
I am Hugh Gregory Mark Bricknell, Senior Coroner for County of Herefordshire
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 13 January 2023 I commenced an investigation into the death of Nicola Jane LACEY. The investigation concluded at the end of the inquest on 12 June 2024. The conclusion of the inquest was suicide.
4CIRCUMSTANCES OF THE DEATH  
Nicola Jane Lacey lived alone in a large property in rural Herefordshire. She had recently separated from a partner. On the 30th December 2022, the deceased did not attend work and did not call anyone. This raised concern. As a consequence a member of staff who worked with the deceased attended her address. There was no answer at the address and therefore the Police were called. Police attended the scene and forced entry. The Police established that Nicola Jane Lacey had died. A note identified the deceased’s intentions.  

Nicola Jane Lacey had a responsible position within Healthcare.
5CORONER’S CONCERNS
During the course of the inquest the evidence revealed matters giving rise to conce rn. 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) Procedures should be clear and known to employers concerning the appropriate disclosure of a colleagues ongoing mental health difficulties for the benefit of both the individual concerned and the safety of the wider public.
6ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe you, Robert Mackie 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 21 August 2024 I, the coroner, may extend the period.
 
Your response must contain details of action taken or proposed to be taken, sett ing out the timetable for action . Otherwise you must explain why no action is pro posed.
8COPIES and PUBLICATION
I have sent a copy of my report to the Chief Coroner .
 
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 co roner , at the time of your resp onse, about the release or the publication of your response by the Chief Coroner.
926th June 2024