Jade Rayner · Prevention of Future Deaths report

On 31st March 2020 I commenced an investigation into the death of Jade Rayner. The investigation concluded on the 6th April 2021 and the conclusion was one of accidental death. The medical cause of death was 1a Toxic effects of fluoxetine.

Jade Nicole Rayner was significantly impacted by domestic abuse and used alcohol to help her deal with the underlying mental trauma from it. She developed seizures and was prescribed medication for them and antidepressants for her mental health. As a result of the mental trauma, alcohol use and seizures, she was a vulnerable adult with complex mental and physical health needs. She had fluctuating capacity. Her vulnerability, fluctuating capacity and the complexity of her needs required effective communication between agencies and an effective multi agency strategy to address them and reduce the risk she presented. Such a plan was not in place. On 30th March 2020 Jade Nicole Rayner was found unresponsive at her home address. Post-mortem examination included toxicology. She was found to have in her system a fatal level of her prescribed antidepressants and alcohol at a level that would cause significant intoxication.

1. The inquest was told that her capacity fluctuated and she was vulnerable. Her social worker reported to Greater Manchester Police and to NWAS that it was believed she had been the victim of a sexual offence involving an employee of NWAS who had initially been to her address in a professional capacity. The inquest heard that NWAS dealt with this robustly through their internal disciplinary process. The inquest was told that GMP did not record it as a crime. The officer giving evidence to the inquest initially gave evidence that GMP had 72 hours to decide if GMP should record a sexual allegation as a crime. It was then indicated that it should have been recorded as a crime. The inquest was told it was not investigated and was written off following a strategy meeting. Jade Rayner was not as a consequence offered by GMP the support set out within the Victims Code.

2. Her case was complex, and the evidence was that there was not a clear multi agency strategy to support her particularly to share information and understand the relationship between earlier Domestic abuse and the subsequent use of alcohol.

3. The evidence was that the existing available alcohol misuse support programmes whilst useful could not meet the needs of a complex case such as this where underlying trauma was a key driver.