MARGARET CAROLE ANN PEGNALL · Prevention of Future Deaths report

On 19 May 2015 I commenced an investigation into the death of MARGARET CAROLE ANN PEGNALL, AGE 69 YEARS. The investigation concluded at the end of the inquest on 22 December 2015. The conclusion of the inquest was Medical Cause of Death: 1a) Multiple Injuries and the Conclusion: Suicide.

On 18 May 2015 Mrs Pegnall stepped into the path of a train at Stracey Arms, Norwich. She turned her back on the train and raised her arms. She was hit by the train and died as a result of her injuries.

(1) Mrs Pegnall went to see her GP on 19 January and 12 March 2015 regarding difficulties she was having with her husband. The GP asked questions with regard to depression using a Flowchart attached to the Surgery’s Policy on Domestic Violence and Abuse. Mrs Pegnall wrote letters to the Practice referring to her interaction with the Police. Mrs Pegnall telephoned the Practice on the day of her death asking to speak to a particular GP who was absent requesting “intervention”.
(2) The Flowchart for Responding to Domestic Abuse is vague and uses an Assessment of Risk pertaining to depression and not to the risk of abuse
(3) There is no Questionnaire specific to Domestic Abuse to assist in recognising signs of abuse and standardising the Surgery’s GPs’ response to concerns raised.
(4) There was no method available to members of staff to recognise when a patient’s call should be escalated and dealt with immediately.