Marc Bennett

Date of report: 9 June 2021 Ref: 2021-0203 Deceased name: Marc Bennett Coroner name: Ian Arrow Coroner Area: Plymouth Torbay and South Devon Category: Community health care | Mental Health related deaths | Suicide (from 2015) This report is being sent to: Devon Partnership Trust and Devon County Council

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS

THIS REPORT IS BEING SENT TO:

Devon Partnership Trust Devon County Council

CORONER

1am lan Arrow, Senior Coroner for Plymouth Torbay and South Devon

CORONER’S LEGAL POWERS

| make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.

http://www. legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7

http://www. legislation.gov.uk/uksi/2013/1629/part/7/made

INVESTIGATION and INQUEST Marc David Bennett Opened 27' May 2020

Concluded 9 June 2021

CIRCUMSTANCES OF THE DEATH

On the balance of probability the deceased was distressed by his children being taken into foster care. He fashioned a ligature to end his own life at his home address on 24th May 2020

Took own life.

CORONER’S CONCERNS

During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you.

The MATTERS OF CONCERN are as follows. —

Lessons learned and submitted in the report by Devon Partnership Trust were, there is a need to ensure improved communication by DPT staff with Children’s Services when children are undergoing S47 Child Protection investigations, and/or planning is taking place for care proceedings, to ensure appropriate support to parents open to DPT services with mental health problems

OFFICIAL

ACTION SHOULD BE TAKEN

In my opinion action should be taken to prevent future deaths and | believe you have the power to take such action.

Please review and explain what steps have been taken at an Executive level to ensure improved communication

YOUR RESPONSE

You are under a duty to respond to this report within 56 days of the date of this report, namely by 4 August 2021. I, the coroner, may extend the period.

Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed.

COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the following Interested Persons

Devon Partnership Trust Devon County Council

| am also under a duty to send the Chief Coroner a copy of your response.

The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to mey the coroner, at the time of your response, about the release or the publication of yur pose by the Chief Coroner.

Dated 09/06/2021

Signature,