Prevention of Future Deaths reports · 2013
Regulation 28 report to prevent future deaths, reference 2013-0204, written 12 Dec 2013. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 12 Dec 2013 |
|---|---|
| Reference | 2013-0204 |
| Deceased | Felix Cembrowicz |
| Coroner | Terence Moore |
| Coroner area | Avon |
| Category | Mental Health related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text recovered by OCR from a scanned PDF. OCR is imperfect: check anything you rely on against the source PDF. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1)
NOTE: This form is to be used after an inquest.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
1.
Managing Director
Avon and Wiltshire Mental Health Partnership Trust
Jenner House, Langley Park Estate, Chippenham
Wiltshire SN15 1GG
1 | CORONER
lam Terence G. Moore, Assistant Coroner, for the area of Avon
2 | 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.
[HYPERLINKS]
3 | INVESTIGATION and INQUEST
On 13th September 2012 | commenced an investigation into the death of Felix Stefan
CEMBROWICZ , Aged 32. The investigation concluded at the end of the inquest on 3rd
September 2013. The conclusion of the inquest was
la Hanging
CONCLUSION: Felix took his own life whilst awaiting a planned mental health
assessment, following deterioration in his mental health
4 | CIRCUMSTANCES OF THE DEATH
Mental health problems and being seen by mental health team. Found hanging at HA,
admitted to Bristol Royal Infirmary,, deteriorated and died
5 | 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. —
The electronic Rio record system used by staff to access patient histories
was introduced in May 2011 when only the documentation for current patients at that
date was migrated across to the new system. Discharged patients, with both a long and
recent history of contact with mental health services do not appear to have had
important records transferred including relapse management plans leaving staff
unaware of a patients history or delaying assessments until old records can be
obtained.
6 | ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and | believe you and
your organisation have the power to take such action.
7 | YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report,
namely by 7” November 2013.. |, 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.. | have also sent it to
1am 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 me, the coroner, at the time of your
response, about the release or the publication of youf\response by the Chief Coroner.
[DATE]
{SIGNER BY CQRONER]
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42 September 2013 Terence G, Moo!
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
Avon and Wiltshire NHS Mental Health Partnership NHS Trust Terence G Moore Assistant Coroner Chief Executive Jenner House County of Avon Langley Park The Courthouse Chippenham Old Weston Road Wiltshire Flax Bourton SN15 1GG North Somerset - BS48 1UL Tel: 01249 468000 Fax: 01249 468001 6 November 2013 Dear Mr Moore | am writing in response to the Regulation 28 report that you issued following the inquest held into the death of Felix Cembrowicz deceased. Thank you for drawing your concerns formally to my attention and providing me with the opportunity to update you on the changes that we have made. Data Migration | think it is helpful to set out our approach to the migration of data you refer to. Our electronic records system (RiO) was introduced in May 2011 and Felix Cembrowicz’s records were included in the ‘active cohort’ of records that were migrated from our old system (MHIS) to RiO. The active cohort for migration was defined as: “clients who have had activity with phase three/four care options in the current financial year, the previous financial year and the six months prior to that (01/10/2009)”. Mr Cembrowicz had two referrals made in February 2011, which were discharged, but as you can see from the criteria above, he was clearly in the ‘active cohort’. The migration of activity only (which did not include documents) from MHIS into RiO was in accordance with the nationally agreed standards as agreed by the National Programme for IT and Mr Cembrowicz's activity was migrated from MHIS into RiO. The Trust decided to migrate specific documents from MHIS to RiO. Team members were explicitly instructed to identify documents to be uploaded to RiO (guidance was provided within the Rio data migration strategy) and were instructed to place these documents in a ‘RiO documents for transfer foider' within MHIS. The migration team then uploaded these documents into the RiO clinical correspondence module. Only one document, ‘AWP Initial Assessment’, was identified by the team for Mr Cembrowicz, which was migrated across on 21 February 2011. Therefore, the relapse management plan was not in RiO, because the team had not saved it in the folder for migration into RiO. Trust Headquarters Chief Executive Jenner House, Langley Park fain Tulley Chippenham, SN15 1GG The information was available within MHIS, which staff still had access to at the time, and in the paper record, which was located in the office where Mr Cembrowicz’s care was being co-ordinated from. Quality Improvements In response to your concerns, we have taken the following steps: « When patients are re-referred it must be established if they have historic plans such as relapse management plans, and an additional check should be undertaken in the RiO clinical documents to establish if they have been migrated across. * Additionally, searches of both the historic electronic (MHIS) and paper records should be undertaken to see if any of the following documents, as per the RiO data migration strategy exist for the previous 24 months from the date of referral and, if so, they should be copied across. The documents are: o Current CPA documents: > ..Core assessment - Risk assessment - Care plan - Latest review - Acute CPA review o Specialist assessments: - Psychology, OT and other therapy assessments o Other documents: - Any comprehensive summaries ~ Consultant letters - Referral letter - Mental Health Act reports (including tribunal reports) This requirement is included in the current initial assessment/admission process. We are using our supervision processes with staff to communicate these new requirements as well as updating our RiO and information governance training packages. We also see the inclusion of this information in the RiO record as a clinical and quality indicator and plan to audit the implementation of this change through our records audit plan. ! do hope that this letter reassures you that we have responded appropriately to your concerns, however, if you would like any further information then please let me know. _ Yours sincerely ie a SO lain Tulley Chief Exec
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