Prevention of Future Deaths reports · 2013
Regulation 28 report to prevent future deaths, reference 2013-0229, written 12 Sep 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 Sep 2013 |
|---|---|
| Reference | 2013-0229 |
| Deceased | Matthew Dunham |
| Coroner | William Armstrong |
| Coroner area | Norfolk |
| Category | Mental Health related deaths |
| Organisation named | Norfolk and Suffolk NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
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.
Norfolk and Suffolk [Vi NHS Foundation Trust Trust Management nec UVTI pete sept Drayton High Road Mt WA: Hellesd ee eae NR6 5BE WY KA 6 November 2013 Private and Confidential Ms Jacqueline Lake HM Coroner Norfolk Coroner's Service 69-75 Thorpe Road Norwich Norfolk NR1 1UA Dear Ms Lake Re: Inquest into the death of Matthew Dunham concluded on 4 September 2013 | write in response to the report dated 12 September 2013 from Mr Armstrong. Following the conclusion of the inquest into the death of Matthew Dunham the Trust was asked to consider a number of aspects of service delivery under Schedule 5 of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (investigations) Regulations 2013. | respond to the areas you highlighted: A) An emergency referral by the general practitioner to the assessment team on the 4" of April 2013 was not followed up within the normal time scale of four hours and it was two days before a telephone triage session took place and four days before an assessment was undertaken by a mental health nurse. This raises the need to ensure that emergency referrals are dealt with within the appropriate time scales and that policies and procedures are in force to make sure that this happens. The Trust’s internal investigation (Root Cause Analysis) identified this gap in responding to the requested assessment. Since this period the service has made a number of resource changes to be in a position to respond to referrals within the specified time period, according to the assessed urgency. The Trust has implemented monitoring mechanisms for the four hour ‘urgent referral’ standard which is reported daily to commissioners and is monitored by senior managers and clinicians. Additionally, the Clinical Team Leader for the Crisis Resolution and Home Treatment (CRHT) team reviews all assessment requests each day to confirm that contact was made within the 4 hour timeframe and that where possible this is a face to face contact. If this is not possible, then a minimum standard of telephone contact has been agreed and put in place. This includes an assessment of risk, support mechanisms available and ensuring the service user has contact details in case the situation deteriorates. Ra KY, x, DIVERSITY CHAMPION “y $. ae Ms Lake -2- B) There appears not to have been a clear shared understanding between professionals as to which team it was appropriate to refer Mr Dunham to. There was some lack of understanding revealed as to whether a referral to the assessment team or the crisis resolution and home treatment team was appropriate. This highlights the need for there to be a clear understanding about the roles of each team and the interface between them. The Trust's internal investigation recognised that with the symptoms presented to the practitioner on the 8 April 2013, it would have been proportionate to have requested the support of the Crisis Resolution and Home Treatment (CRHT) team. To enhance the interface between the two clinical teams, Access and Assessment Team (AAT) and CRHT, a member of the CRHT is now based within the AAT. This enables joint working without any delay, supporting transition of care between the two teams. The Trust is monitoring its effectiveness in identifying people in need of this crisis support. C) On the 8 April 2013, despite the fact that Mr Dunham was presenting as feeling suicidal and specifically that he had set up a noose in his flat the previous night, it was not thought appropriate to refer him to the Crisis team for appropriately robust intervention. This raises the issue of the basis upon which the risk of suicide or serious self harm is recognised and acted upon particularly where the person concerned has gone beyond vague suicidal ideation and moved towards contemplating some specific ways of ending his life. The Trust accepts that on the 8 April Mr Dunham presented with a number of factors associated with people having suicidal thoughts. As noted above it is recognised that it would have been proportionate to refer Mr Dunham to the Trust's CRHT at that time. This would have enabled the opportunity for an assertive intervention aimed at identifying and supporting his needs. The Trust's internal investigation recognised that the AAT is a new service (commenced in February 2013). The investigation recommended that an audit be completed to seek assurance on the robustness of the assessment structure, both from the perspective of the framework and clinician’s individual judgements within it. This will provide the evidence to support further developments in the assessment of suicide risk alongside the Trust's current mandatory training programme. This audit is currently in progress and | would be happy to share a copy of its report upon conclusion. D) A letter sent to Mr Dunham's general practitioner from the advice and assessment team was not draft appropriately. This raises the issue if the need for specific guidance to be given about how such letters should be drafted within a template structure. The Trust's internal investigation identified that whilst all of the information was within the letter to the GP it was presented in a way that key aspects were not readily visible. To address this, the AAT have been working with general practitioners to develop a template that provides information in a manner to meet their needs. The agreed template is due to be implemented from the 18" November 2013 E) Most disturbingly the evidence at the hearing displayed a lack of coordination between mental health professionals involved in Mr Dunham’s care. Specifically when a mental health nurse saw Mr Dunham on the 8 April he had no knowledge whatsoever that Mr Dunham was already being seen by a psychological wellbeing practitioner. This clearly demonstrates the need for effective information sharing between professionals involved in managing the care of a mentally ill person and the need for each and every professional to have access to all the records relating to the patient and details of interventions and actions by other practitioners. It is recognised that the Trust is working towards the implementation of a single electronic health record in 2014. © ABOz, ~ > s & aWWe EMPLOYER Stonewall 1s DIVERSITY CHAMPION Ms Lake -3- The Trust's internal investigation confirmed that the computer system employed by AAT at the time was able to scan all the Trust electronic health record systems with the exception of the electronic health record system named PC Mis. This meant that it was not readily identified if a patient was attending the Trust's Improving Access to Psychological Therapies (IAPT) service. The Trust has now implemented an updated system (Apervita) which is able to include the system PC Mis and therefore identify any current or historical care episodes an individual has with the IAPT service. As you recognise, the Trust is in the process of working towards a single electronic health record across all of its services. This will bring together a number of different electronic and paper based record systems bringing a number of benefits to increase patient safety. Thank you for bringing these matters to the Trust's attention which assists to provide focus in improving patient safety for service users. The Trust is committed to applying as much learning as possible from this tragedy. Yours sincerely Acting Chief Executive sronewall DIVERSITY CHAMPION S\ ‘S. ~ & 3 YY Ss MINDFUL * o EMPLOYER
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: The Chief Executive PS Norfolk and Suffolk NHS Foundation Trust Trust Headquarters Hellesdon Hospital Drayton High Road Norwich NR6 5BE 4 | CORONER \ | am William James Armstrong, Senior Coroner; for the area of Norfolk. 2 | CORONER’S LEGAL POWERS I 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. 3 | INVESTIGATION and INQUEST On the 15" of May 2013 | commenced an investigation into the death of Matthew Christopher Dunham, who was 25 years old at the time of his death on the 9" of May 2013. The investigation concluded at the end of the inquest on the 4" of September 2013. It was found that the cause of death was multiple injuries as a result of a fall and the conclusion of the inquest was “Suicide whilst suffering from mental disorder and whilst in receipt of mental health services. 4 | CIRCUMSTANCES OF THE DEATH Matthew Christopher Dunham, who was suffering from mental disorder and receiving professional mental health services at the time, leapt from the fifth floor of a shopping mall known as Castle Mall in Norwich. He fell to the ground. Assistance was provided straight away and medical attention given expeditiously. Sadly he could not be saved and was pronounced dead at the scene. Mr Dunham had been seen by various mental health professionals since February 2013 and had recently been expressing suicidal ideation. ss) CORONER'S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern and, in my opinion, there is a risk that future deaths will occur unless action is taken. | fully accept that since this tragedy the Trust has instigated an internal review and is committed to taking a number of measures as a result of lessons learned from this tragedy. The MATTERS OF CONCERN are as follows. — ‘a) An emergency referral by the general practitioner to the assessment team on the 4" of April 2013 was not followed up within the normal time scale of four hours and it was two days before a telephone triage session took place and four days before an assessment was undertaken by a mental health nurse. This raises the need to ensure that emergency referrals are dealt with within the appropriate time scale and that policies and procedures are in force to make sure that this happens. b) There appears not to have been a clear shared understanding between professionals as to which team it was appropriate to refer Mr Dunham too. There was some lack of understanding revealed as to whether a referral to the assessment team or the crisis resolution and home treatment team was appropriate. This highlights the need for there to'be a clear understanding about the roles of each team and the interface between them. . c) On the 8" of April 2013, despite the fact that Mr Dunham was presenting as feeling suicidal and specifically that he had set up a noose in his flat the previous night, it was not thought appropriate to refer. him to the crisis team for appropriately robust intervention. This raises the issue of the basis upon which the risk of suicide or serious self harm is recognised and acted upon particularly where the person concerned has gone beyond vague suicidal ideation and moved towards contemplating some specific way of ending his life. d) A letter sent to Mr Dunham's general practitioner from the advice and assessment team was not drafted appropriately. This raises the issue of the need for specific guidance to be given about how such letters should be drafted within a template structure. . e) Most disturbingly the evidence at the hearing displayed a lack of coordination between mental health professionals involved in Mr Dunham's care. Specifically when a | mental health nurse saw Mr Dunham on the 8" of April he had no knowledge whatsoever that Mr Dunham was already being seen by a psychological wellbeing practitioner. This clearly demonstrates the need for effective information sharing between professionals involved in managing the care of a mentally ill person and the need for each and every professional to have access to all the records relating to the patient and details of interventions and actions by other practitioners. It is recognised that the Trust is working towards the implementation of a single electronic health record in 2014. : N.B. It is fully recognised that the Trust has commendably committed itself to learning lessons as a result of this tragedy. However, the inadequacies revealed in what | described at the inquest as the “fragmented and uncoordinated” approach to Mr Dunham's care clearly demonstrate the need for these issues to be addressed speedily and comprehensively in the interests of seeking to reduce the possibility of further fatalities. ACTION SHOULD BE TAKEN In-my opinion action should be taken to prevent future deaths and | believe your organisation has the power to take such action. YOUR RESPONSE You are under a duty to respond to this report within 60 days of the date of this report, namely by 11 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 I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: : A (mother) Spixworth Norwich NR10 (father) Stanfield Wymondham NR18 = ity = Patient Safety Manager, NHS Anglia Commissioning Support Unit Lakeside 400 Old Chapel Way Broadland Business Park Norwich NR7 OWG Healthwatch Norfolk The Business Base Ltd Rowan House 28 Queens Road Hethersett Norwich NR9 3DB Derek Winter (Archivist) HM Coroner for the City of Sunderland Civic Centre Burdon Road Sunderland SR2 7DN 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. 12 September 2013 | le __ fee
See every Prevention of Future Deaths report matching Norfolk and Suffolk NHS Foundation Trust, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.