§ Mr. French
To ask the Secretary of State for Health whether his Department has completed its consideration of the reports from the health and social services authorities and the coroner's report on the death of Beverley Lewis; and what further action he intends to take.
§ Mr. Dorrell
Following the death of Beverley Lewis on 17 February 1989 the Gloucester health and social services authorities both launched internal inquiries into the circumstances surrounding Beverley's death. The two inquiries made joint recommendations which were submitted to the coroner at the inquest. The coroner delivered a verdict of death by natural causes. The health and social services authorities' reports identified three areas where improvement in procedure are necessary and they are acting upon them:
- (a) An "at risk" procedure is being introduced for adults with a physical or mental handicap or who are suffering from mental illness.
- (b) Management of the community mental health teams is being strengthened.
- (c) Individual programme plans are being implemented for each individual with a mental handicap.
I have reviewed the reports of both the health and social services authorities as well as the coroner's findings. The 432W social services inspectorate will work with the local health and social services and education authorities to learn, apply and disseminate the lessons of this tragic case and I have asked the Law Commission to consider and advise on the coroner's view that the relevant legislation needs to be clarified. In view of the extensive local inquiries, the coroner's verdict, the continuing involvement of the SSI, and the need for local management to concentrate on implementing the changes that have now been agreed, I have decided not to establish a further inquiry into the circumstances of Beverley Lewis's death.