LORRAINE SHEILA YOUNGS · Prevention of Future Deaths report

On 27 March 2015, an investigation was commenced into the death of LORRAINE SHEILA YOUNGS aged 35 years. The investigation concluded at the end of the inquest on 27 January 2016. The conclusion of the inquest which was held before a jury was that she killed herself by a deliberate act but it is unclear if she intended to kill herself. The medical cause of death was 1a: Hanging.

At the time of her death Lorraine Young's was a detained patient at Hellesdon Hospital. She was discovered on 24 March 2015, unresponsive in the public pay phone room on the ward having wrapped the telephone cord around her neck. A pulse was regained but she sadly died at Norfolk and Norwich Hospital 2 days later.

The inquest heard evidence regarding Lorraine Young's care in the community. Evidence was given from Lorraine's social worker that a care package had been agreed in principle at a visit on 12 February 2015. At the time of her death, this had not been implemented. The evidence given was that this had not been followed up. Whilst it could not be said in the context of Lorraine's death whether the delay affected the outcome, I was concerned that a delay in following up implementation of an agreed care package could, in different circumstances, affect the outcome for a vulnerable Service User. The evidence before the inquest was that there appeared to be no system for following up implementation of an agreed care package.