Benjamin Orrill · Prevention of Future Deaths report

On 13th June 2016 I commenced an investigation into the death of Benjamin Orrill.

The Inquest concluded on 19th September 2016

Cause of death:

1a Multiple injuries

Conclusion:

Suicide

Mr. Orrill died on 12th June 2016 following a fall from Lee Circle NCP car park, Leicester. He had been reviewed by an advanced nurse practitioner in the weeks leading up to his death due to feeling suicidal. There was a missed opportunity to appropriately assess the severity of Mr. Orrill's low mood, however there was no evidence heard to suggest that this would have prevented the outcome. Police investigation concluded that there were no suspicious circumstances, that these were Mr. Orrill's own actions and that he did intend the outcome.

During the course of the Inquest it came to my attention that there is no regulatory body for advanced nurse practitioners. It would appear they are not subject to the same stringent appraisal and revalidation processes such that GPs currently are, despite the fact that they may perform similar duties and can have parallel roles.

I also became aware that some advance nurse practitioners may independently buy into a partnership and may not have an employer directly responsible for their appraisal. Therefore some may potentially be operating as independent practitioners without any supervision or regulation. I am concerned that this may have a significant impact on patient safety.