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Investigation and inquest
On 4 May 2021 I commenced an investigation into the death of Paige Jeannette ALLEN . The investigation concluded at the end of the inquest 25/05/2023. The conclusion of the inquest was Misadventure.
The medical Cause of Death determined to be:-
1a Multiple Blunt Force Injuries
1b
1c
II
Circumstances of the death
Paige Allen had a diagnosis of Emotionally Unstable Personality Disorder. Symptoms of this disorder included impulsive risk-taking behaviour at times of high anxiety. On the late evening of 20.4.21 into the early hours of 21.4.21 she has travelled to Southerndown Cliffs, ████████ She has contacted the emergency services who have attended and attempted a rescue. It is more likely than not, that during the same she has lost her footing, her ability to remain in position and fallen to her death. Her death was confirmed at 3.07am on 21.4.21. At the time that she left the cliff edge it was not found that she deliberately did so.
Coroner’s concerns
Whilst I did not find that the matter of concern outlined below was directly causative of, nor contributory to, Miss Allen’s death, my concern broadly is that those patients who contact mental health services in Cwm Taf Morgannwg University Health Board (CTMUHB), especially at the time of crisis may be assessed without the assessing practitioner having immediate & comprehensive access to relevant and proximate medical records, notes & plans (such as WARRN assessments, & Care & Treatment Plans).
More particularly, the evidence indicated that should a patient present to mental health services in the Bridgend locality, but have their secondary mental health care managed in either the Merthyr/Cynon locality or the Rhondda/Taff/Ely locality or vice versa, the assessing practitioner will not immediately i.e. at the time of assessment, have access to that patient’s FACE records.
My concern is that this has the potential to deprive the assessing practitioner of pertinent and proximate material which may increase the risk of an incomplete or insufficient assessment.
That being potentially significant in informing the assessing practitioner of his/her action/planning for that individual in crisis.
Whilst I received evidence that CTMUHB has pledged to adopt a system, which it is believed will ameliorate the current situation, I am concerned that until such time as the same is available and immediately accessible across the three localities, the risk identified persists.
Interim measures may wish to be considered to mitigate the risk identified.
Information checked against the published report and official responses