Tessa Karen Elizabeth Summers · Prevention of Future Deaths report

On 18th September 2013 I commenced an investigation into the death of Tessa Karen Elizabeth Summers, Aged 20.

The investigation concluded at the end of the inquest on 3rd July 2014.

The conclusion of the inquest was:
Medical Cause of Death:
1a. Morphine Toxicity

Coroner’s Conclusion as to the Death:
Death due to an Accident

1 At about 10.00 hours on 9th September 2013 Tessa Karen Elizabeth SUMMERS was found in bed in a collapsed state. An ambulance was called and paramedics attempted to resuscitate her en route to Queen Alexandra Hospital. Resuscitation continued after arrival at the hospital but was unsuccessful and she was pronounced deceased at 11.18 hours on that day.

2. Tessa, who had complex emotional problems, had taken an overdose of her medication as a kind of gesture. She had previously behaved in a similar way but had obtained help before her life was endangered. From the evidence I heard, I believe it was Tessa’s intention when she took the overdose that she would seek medical help later the next day.

1. I heard in evidence that the social workers who decided on amendments to Tessa’s risk assessment did not record in that document their rationale for downgrading her from high to low risk of self-harm and allowing her to have access to her medication which she could then take without supervision by her Shared Lives Carer. I was told the social workers were not required to do so as a matter of routine to record why details of risk assessments for any of the clients were being changed.
2. I gained the impression from some of the inquest witnesses that Adult Social Services could beneficially provide more training and support for Shared Lives Carers where the carers would be called upon to work with clients with mental health and emotional problems.