Prevention of Future Deaths reports · 2013
Regulation 28 report to prevent future deaths, reference 2013-0213, written 21 Aug 2013. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 21 Aug 2013 |
|---|---|
| Reference | 2013-0213 |
| Deceased | John Walker |
| Coroner | Christopher Wilkinson |
| Coroner area | West Sussex |
| Category | Mental Health related deaths |
| Organisation named | Sussex Partnership NHS Foundation Trust |
| 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 THIS REPORT IS BEING SENT TO: 1. Lisa Rodrigues, Chief Executive, Sussex Partnership NHS Trust, Swandean, Arundel Road, Worthing, West Sussex BN13 3EP CORONER | am Christopher Wilkinson, assistant coroner, for the coroner area of West Sussex 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. INVESTIGATION and INQUEST On the 6” June 2012 the senior coroner for West Sussex commenced an investigation into the death of JOHN LEON NAYLOR WALKER born 12 September 1940, being age 71 at the date of his death. The investigation concluded at the end of the inquest on 21 May 2012 following two days of evidence (on 3 May and 21 May 2012). The conclusion of the inquest was that Mr Walker had died as a result of hanging and that he had taken his own life whilst suffering from depression and anxiety. CIRCUMSTANCES OF THE DEATH 1. Mr Walker had a history of mental health issues which developed in 2006 when he suffered a sudden breakdown, attempting two overdoses of prescription medicine. He was gradually helped back to full mental health by 2009 and lived a reported full and illness free life until March 2012. 2. On 19 March 2012, an altercation with a neighbour triggered a further breakdown, as a result of which, via referral to Mental health services, he was hospitalised as a voluntary patient at Langley Green hospital, West Sussex on 10 April 2012 with symptoms of depression and suicidal ideation. Langley Green is not a Psychiatric Intensive care unit (i.e. it is not secure), but it does control visitors to the wards and monitors its patients. 3. Mr Walker stabilised on the ward, which he had described as a safe environment where he felt he could be protected from his impulsivity to self-harm in times of low mood. 4. Despite repeated denials about on-going suicidal ideation, and an apparent improvement in his condition, Mr Walker made a further serious and impulsive attempt on his life on 19 April whilst on a visit home. 5. Mr Walker was subsequently released from the hospital's care on 1 May 2012, under supervision of the Crisis Resolution Team. He continued to express suicidal thoughts to his family and on 14 May made a further opportunistic attempt on his life when his wife was distracted for a period of 10mins on the phone. 6. Following an assessment at a local hospital (St Richard's) on 14 May, Mr Walker was re- admitted, as a voluntary patient, to Langley Green on 17 May 2012. He was assessed on admission by a second year core trainee in Psychiatry, who whilst having sight of his transfer notes, could not recall reviewing the ‘e-notes’ on the system (which would have been her normal practice) and did not have available to her notes from Mr Walker's 1* admission to the hospital as they were at another location for Mr Walker's discharge summary. A full assessment was undertaken with Mr Walker in person, but the Dr did not get an opportunity to meet or discuss matters with his wife. 5981872.1 7. The assessment considered the prior attempts on his life and the apparent speed and impulsivity with which they had been undertaken. His playing down of their severity in interview was taken as an indication that his risk was unlikely to have changed quickly and he was admitted on eyesight observations on account of the perceived high risk that he posed to himself. 8. In evidence, the Dr felt sure that she would have conveyed the issues over his impulsivity and speed of action to nursing staff, and whilst it was noted in her notes that his risk was ‘very difficult to assess’ it was clear that the wider picture of these factors had not been fully ascertained. In evidence, pe Aad described how she had explained on a number of occasions to the hospital the fact that Mr Walker was impulsive but that he had good insight into his condition and understood and feared his impulsivity. Mr Walker, it was said by his wife, described himself frequently as ‘needing to be protected’ and ‘to be kept safe until his medication worked’ The Dr was not aware of comments and specific concerns which had been raised by the family and it appears therefore that these were not effectively conveyed. It was believed by the Dr however that the nursing staff would have been aware of these matters from previous contact. 9. On 18 May, observations were reduced to 10 minutes. 10. On 19 May a risk care plan for Mr Walker was prepared. This was undertaken by a temporary charge nurse without, it appeared, wider input from the MDT. The nurse, the evidence established, had not been present at admission. The risk care plan was based on admission notes, but was not informed by any wider discussions with the MDT or family. It was not recalled as to whether it was subsequently discussed with staff. The risk plan was described as only being meant to be a ‘stop gap’ as a guide for the team, in the belief that a future risk assessment would be undertaken. It proved however to be only a factual recount of the events leading up to Mr Walker's admission, failed to expand or consider any of the comments raised in the admission assessment and made no mention of impulsivity, known triggers, protective factors, or of the speed with which Mr Walker could act, which was of particular concern to the family. No further risk assessment was undertaken or risk care plan prepared, although the inquest was not able to establish why. 11. On 19 May observations were reduced to 15 minutes and on 24 May, were further reduced to 30 minutes. There was no clear indication in the notes as to the reasoning for this, decisions it was established being based on MDT discussions, recording only the changes in observations and not the rationale. Observations remained at 30 minutes until 1 June 2012. 12. On 1 June, at some point just after 10.30am, following the 30 minute observation, Mr Walker, with the assistance of a stool from the common room, scaled a 2m fence surrounding the ward's courtyard, entered the outer gardens of the hospital, scaled a further exterior fence and travelled a distance of approximately 0.25 miles on foot before coming across a secluded area of wood by grazing fields. 13. The evidence showed that Mr Walker found a length of fencing tape at the location which he used to suspend himself from a tree at some time between 11 to 11.15am. Mr Walker was not discovered missing from the hospital until the next observations round for him at 11am. The Police were called (following the instigation of the hospital's AWOL policy and a thorough search of the hospital) at 11.50am. Police confirmed that Mr Walker was discovered by passers-by at approximately 11.15am that morning. 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. — (1) The consideration of, contribution to and preparation involved in risk care planning for Mr Walker was insufficient in its scope and depth in order to provide any informed basis on which an active and proper assessment of his continuing risk (factors) could be made. Properly detailed, and the issues communicated amongst all members of the MDT, this may have better informed thinking with regard to the observation levels set. It is of concern that this risk care plan was neither revisited nor revised. There was no clear rationale provided for changes in observation levels in the notes or any explanation given in writing as to the considerations or risk factors taken into account. Whilst accepted that these matters may have been discussed, written evidence would have provided clarity and a point of reference for further assessment in light of any change in presentation or condition. The fact that observation levels only decreased (despite evidence heard at the inquest (2 that Mr Walker was expressing ever darker and suicidal thoughts in the week before his death), 1 5981872.1 without explanation, remains of concern. (3) Whilst it was accepted in evidence that the hospital's AWOL policy was robust and activated and implemented appropriately, concern was raised by the family with regard to the length of time taken before Mr Walker could be declared missing and the police informed. (4) At the time of the incident the fences surrounding the external common areas of the ward were of a scalable height by any patient determined enough to do so. It is accepted that this has been subsequently addressed. 6 | ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you and Langley Green Hospital 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. 8 | COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the following Interested Persons: 4, ife of the deceased; and 2 Legal Support Manager, Sussex Partnership NHS Foundation Trust lam 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 your response by the Chief Coroner. 9 | DATE: 21/08/13 SIGNED: Christopher Wilkinson, Assistant Coroner, West Sussex 2 Secs ETS ‘ 2 5981872.1
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.
A teaching trust of Brighton Sussex Partnership NHS] and Sussex Medical School . NHS Foundation Trust 5 ‘ii del Re Mr Christopher Wilkinson abe Assistant Coroner West Sussex BN13 3EP Coroner's Office West Sussex Record Office Orchard Street Chichester PO19 1DD Dear Mr Wilkinson Re: Inquest into the death of John Leon Naylor Walker — 24 May 2013 Thank you for your letter of 22 August 2013, concerning the Inquest into the very sad death of John Walker, and your subsequent Regulation 28 Report. We have now had an opportunity to consider the four areas of concern you have highlighted. 1. Risk care planning It is difficult to respond definitively to your conclusion that the consideration of, contribution to and preparation involved in risk care planning for Mr Walker was insufficient. We do acknowledge that some documentation was not of the standard we would expect. In particular, the Risk Care Plan and the Formulation section of the MDT Clinical Review was poor and so taking this in isolation could imply insufficient risk care planning. However, | think it is important to reinforce the evidence of ME onsuttant Psychiatrist. She explained that the staff caring for Mr Walker did have a good understanding of his risks and that these risks were documented in the Acute Care Risk Assessment, Acute Care Screening and the daily MDT Evaluation and Progress Notes. The point | think you are making is that the identified risks should also have been included in subsequent documents, such as the Risk Care Plan. We completely agree. As | say, the Risk Care Plan for Mr Walker was poor. In recognition of the importance of documentation and to ensure continued learning and improvement, we have since revised the documents clinicians are asked to complete. This is to ensure they are less repetitive and better support succinct recording of relevant issues. Regular audits are completed to ensure adequate standards are met. In relation to how the risk care planning might have affected the decision about observations, again, | refer to the evidence given —_—a She explained that Mr Walker's risk of impulsivity and low mood was carefully considered and that this was why he was nursed on intermittent, every 30 minutes, observations, which is an enhanced level. This was to encourage engagement and to more closely monitor his mental state. Although Mr Walker was ambivalent about the future, he was making some plans and expressing a will to recover. He did not have any history of attempting to harm himself while in hospital, and nor did he Chair: John Bacon CB Chief Executive: Lisa Rodrigues CBE Head office: Sussex Partnership NHS Foundation Trust, Swandean, Arundel Road, Worthing, West Sussex, BN13 3EP www.sussexpartnership.nhs.uk ever try to abscond. This was of significant clinical importance to the treating team when assessing which level of observation was appropriate. Reflecting on the information available to them at the time, the clinicians involved do not believe a different level of observation was clinically indicated. 2. Documented rationale for the observation level We acknowledge that the rationale for changing the level of observation was not documented. The expectation is that this must be written down and this is what is stated in the policy. This is very important and our Nurse Consultant has provided training to staff to help ensure this happens more consistently. The point you make about the absence of documented rationale when observation levels do not change is a slightly different issue. Firstly, the use of observation to provide support and to manage risk is something clinicians consider constantly, and so we would not always expect the rationale to be recorded during periods when the level remains the same. This would only be necessary when there is a significant change in risk, as determined by clinical staff. When reading Mr Walker's records in isolation and with the benefit of hindsight | can see why it may appear as though his risk was changing and | think you probably have in mind the last pe he stated that he had never felt worse. Once more | refer to the evidence of| when, in relation to this last review, she explained this comment was in the context of wanting to start Lithium and was made early on in the review. By the end he appeared more positive and was very much involved in the decisions about his care pe aware that there were times when Mr Walker was expressing suicidal thoughts, but he also stated feeling safe on the ward and never expressed to staff a wish to leave even though he was in hospital voluntarily. It was therefore completely unexpected when he absconded, especially in the way he did. 3. AWOL Staff contacted the Police within 50 minutes of them noticing that Mr Walker was missing. This was after a full search of the ward, hospital, and hospital grounds was conducted, and after attempts were made to contact Mr Walker and his family. It was also the conclusion from our internal investigation that the AWOL policy was implemented appropriately. 4. Fences Opal Ward at Langley Green Hospital is an open ward and so there is no requirement to have fences at a particular height, as would be the case for a secure unit. Had Mr Walker or any other patient at that time been considered a risk of absconding then staff would have taken steps to ensure appropriate supervision; this may have included locking the door to the garden. As you know, the fences throughout Langley Green Hospital have been subsequently altered to make it much more difficult to get over. This was done in order to make it possible to always keep the doors to the garden open, as this promotes a more therapeutic environment. Absconding in the way Mr Walker did we believe was not foreseeable, for the reasons already set out. Mr Walker's death came as a shock to all the staff involved in his care. Please be assured that each one has taken time to reflect and consider the issues that have arisen, including the concerns you have highlighted. | hope this reply is helpful. Yours sincerely WiSe hk : Lisa Rodrigues CBE Chief Executive
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