Jane Dyson Gabbitas · Prevention of Future Deaths report

On 5 March 2013I commenced an investigation into the death of Jane Dyson Gabbitas, aged 52. The investigation concluded at the end of the inquest on 5 December 2013. The conclusion of the inquest was that “Jane Dyson Gabbitas died as a result of ingesting alcohol and gabapentin in sufficient quantities to cause her death, having gone to a place where she would be unlikely to be easily discovered, at a time when she was resident at an open unit in which she had agreed to stay to assist her treatment for depression, and was under the care of the Intensive Home Based Treatment Team of the local NHS Trust” (the Trust). The medical cause of death was l(a) Combined overdose of alcohol and gabapentin.

On 2 March 2013 the deceased was reported missing. A member of the public alerted the police to an abandoned car behind a pumping station off Bar lane, Rippoden, West Yorkshire. The deceased was found unconscious and, despite attempts at resuscitation, life was pronounced extinct at the scene at 18:54 hours.

The SHARE accommodation unit in which Mrs Gabbitas was resident over the short period prior to her death is an open residential unit operated by the Trust and the local authority in partnership; but the Trust in this case was responsible for Mrs Gabbitas’ admission and therefore it is the Trust to whom this report is addressed.

I was at the inquest told that a report had been prepared within the Trust relating to Mrs Gabbitas and I was given a copy of its findings, and noted these. The following matter however was not addressed in the report.

The inquest revealed a period of time on the day of her death from approximately 1.40pm to 6pm when Mrs Gabbitas was absent from SHARE, and she never returned, her body then having been discovered some distance away. Staff at SHARE were aware that she had indicated an intention to go out, but apparently were not aware of the full extent of her absence until telephoned by Mrs Gabbitas’ daughter to say her mother’s body had been found by police. It was not clear if there was any sign-in /out arrangement or any reception facility at SHARE to account for absences.

I consider that, although I did not find that Mrs Gabbitas’ death would have been prevented by earlier attention to her absence, there is a risk that future deaths may occur in similar circumstances if no action is taken to record and monitor absence, albeit informally (in keeping with the nature of the care in the SHARE unit), and to react appropriately to absences which appear to be inappropriate or particularly lengthy.