‘Future deaths will occur unless action is taken,’ warns coroner
PUBLISHED: 09:21 04 November 2019 | UPDATED: 09:21 04 November 2019
A coroner’s report has been made public after an inquest into the death of a teenager.
Tyla Cook, 16, died in the Queen Elizabeth Hospital on November 15, 2017.
Tyla of Church Road, Wretton, was taken to hospital on November 9, 2017, after Norfolk and Suffolk Foundation Trust (NSFT) staff at Thurlow House, in King's Lynn, learned he had taken an overdose.
The inquest heard there were various delays in getting him to hospital and being sedated so he could be taken into A&E.
Norfolk's senior coroner Jacqueline Lake has made a report under the Coroners Act.
"During the course of the inquest, the evidence revealed matters giving rise to concern," it states. "In my opinion there is a risk future deaths will occur unless action is taken." Mrs Lake's report highlights an 11 week delay between Tyla being seen by an eating disorder team, on August 9, and being seen by a specialist on October 25.
It also states there was no up to date care and crisis plan in place. A meeting regarding his case on November 6 heard this would take a further three months.
Tyla's family had repeatedly requested the plan, the coroner notes.
"An interim written plan was not considered, nor that a written plan may have helped the family in providing support to Tyla," he report goes on.
A review carried out by the West Norfolk Clinical Commissioning Group in may recommended a "multi disciplinary learning event" involving the NSFT, Queen Elizabeth Hospital, Norfolk County Council and the East of England Ambulance Service, to train staff on how to apply leadership, task prioritisation and communication when responding to an emergency. Mrs Lake said at the inquest, it became clear no steps have been taken towards organising the event.
The report has been sent to the West Norfolk Clinical Commissioning Group, the NSFT, the Queen Elizabeth Hospital and Norfolk County Council, who have 56 days to respond.
Mrs Lake concludes: "In my opinion action should be taken to prevent future deaths and I believe your organisations have the power to take such action."
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