Investigation and inquest
On 1st December 2016 I commenced an Investigation into the death of LUKE ALF EDWARD MOULDING aged 29. The Investigation concluded at the end of the Inquest on 5th April 2017. The Conclusion of the Inquest was ‘ACCIDENTAL DEATH’. The medical cause of death was:
1 (a) Severe Traumatic Injuries
1 (b)
1 (c)
II Excess Alcohol, Cannabinoids and Opiates Intake
Circumstances of the death
On the 25th November 2016 the Deceased entered the railway line near his home in Westoning in Bedfordshire, having consumed alcohol and drugs. Prior to his death he rang his mother and informed her he was going to get noticed so he could be arrested and then be helped. In the event he collided with a train and died from severe traumatic injuries.
Coroner’s concerns
(1) The Deceased saw ████████, Speciality Doctor in Psychiatry, at Beacon House Community Mental Health Team on 11th November 2016. The deceased left part way through the consultation. ████████ decided an “opt in” letter was required. It was not sent.
(2) The evidence is that “opt in” letters are “normally typed and sent by 10 working days.
(3) There seems to be no reason why a typed letter is required. A pre-printed letter/brochure/card would suffice and give the service users sufficient information, should they require it.