Sarah Sutherland: Prevention of future deaths report
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Date of report: 15/03/2024
Ref: 2024-0148
Deceased name: Sarah Sutherland
Coroner name: Karen Henderson
Coroner Area: West Sussex, Brighton and Hove
Category: Suicide (from 2015)
This report is being sent to: Council of Psychotherapy | Royal College of Psychiatrists | NHS England | Care Quality Commission | Brainwaves
| REGULATION 28 REPORT TO PREVENT FUTURE DEATHS | |
|---|---|
| 1 | THIS REPORT IS BEING SENT TO: Chief Executive, UK Council of Psychotherapy President Royal College of Psychiatrists Chief Executive NHS England Chief Executive CQC Brainwaves |
| 2 | CORONER Dr Karen Henderson, HM Assistant Coroner for West Sussex |
| 3 | CORONER’S LEGAL POWERS I make this report under paragraph 7(1) of Schedule 5 to The Coroners and Justice Act 2009. |
| 4 | INVESTIGATION and INQUEST On 17th December 2023 I resumed an investigation into the death of Sarah Louise Sutherland. On 17th January 2024, the investigation was concluded: The medical cause of death given was: 1a. Suspension I recorded the following in Box 3 of the Record of Inquest: Sarah Louise Sutherland had significant mental health challenges with an ongoing history of suicidal ideation and self-harm. On the 17th December 2022, Ms Sutherland was found to have died by intention through self-suspension at her home address in Redhill having last been known to be alive on the 15th December 2022. I concluded Ms Sutherland died by way of Suicide |
| 5 | CORONER’S CONCERNS Guidelines for regulation and management of private psychotherapists The psychotherapist did not fulfil the UKCP (of which she is a member) Code of Ethics and Professional Practice by failing to keep any clinical records in the care she provided to Ms Sutherland, nor has her practiced changed since Ms Sutherland’s death. The psychotherapist did not at any time undertake risk assessments and blurred if not crossed the boundary of a therapeutic relationship between a therapist and a client. Proactive need for co-ordination of NHS mental Health services and Private Psychotherapy Following Ms Sutherland’s death, Surrey and Borders NHS Foundation Trust have, as long as client consent is obtained, introduced a ‘standard process for communication with private providers of psychological therapies’. However, there is a national lack of co-ordination of treatment and communication between NHS and private providers of mental health care with no formal or informal mechanism or processes in place to liaise with each other to ensure the best mental health care and safety of their clients. |
| 6 | ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe that the people listed in paragraph 1 have the power to take such action. |
| 7 | YOUR RESPONSE You are under a duty to respond to this report within 56 days of its date; I may extend that period on request. Your response must contain details of action taken or proposed to be taken, setting out the timetable for such action. Otherwise, you must explain why no action is proposed. |
| 8 | COPIES I have sent a copy of this report to the following: 1. See names in paragraph 1 above 2. [REDACTED] 3. [REDACTED] In addition to this report, I am 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 at the time of your response, about the release or the publication of your response by the Chief Coroner. |
| 9 | Signed: Dr Karen Henderson DATED this 15th March 2024 |