Prevention of Future Deaths reports · 2013
Regulation 28 report to prevent future deaths, reference 2013-0323, written 3 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 | 3 Dec 2013 |
|---|---|
| Reference | 2013-0323 |
| Deceased | Abdullahi Sharif Abokar |
| Coroner | Mary Hassell |
| Coroner area | Inner North London |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Camden and Islington NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Regulation 28: Prevention of Future Deaths report
Abdullahi Sharif ABOKAR (died 21.06.12)
THIS REPORT IS BEING SENT TO:
1. Ms Wendy Wallace
Chief Executive
Camden & Islington NHS Foundation Trust
4th Floor, East Wing
St Pancras Hospital
4 St Pancras Way
London NW1 0PE
1
CORONER
I am: Coroner ME Hassell
Senior Coroner
Inner North London
St Pancras Coroner’s Court
Camley Street
London N1C 4PP
2
CORONER’S LEGAL POWERS
I make this report under the Coroners and Justice Act 2009,
paragraph 7, Schedule 5, and
The Coroners (Investigations) Regulations 2013,
regulations 28 and 29.
3
INVESTIGATION and INQUEST
On 26 June 2012, my predecessor coroner, Shirley Anne Radcliffe,
commenced an investigation into the death of Abdullahi Sharif Abokar,
aged 22 years.
I finished the investigation at the end of the inquest on 27 November
2013. The jury concluded that death was an accident, when Mr Abokar
hanged himself at approximately 6.20pm on 16 June 2012 at Coral Ward
of Highgate Mental Health Unit.
4
CIRCUMSTANCES OF THE DEATH
Mr Abokar was a patient on a secure mental health ward, detained under
section 3 of the Mental Health Act.
1
He was found on a routine 15 minute check by a support worker, hanging
by a bed sheet from smoke alarm wires pulled out from the ceiling. The
support worker immediately took Mr Abokar’s weight, raised the alarm
and, assisted by another member of staff, got Mr Abokar down.
Several members of staff responded to the alarm (captured on CCTV in
the corridor) and assisted in giving cardiopulmonary resuscitation. Mr
Abokar was taken to hospital, but survived only five days.
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.
1. Asking the suicide question
Several members of staff looking after him did not ask Mr Abokar if he
had thoughts of taking his life.
Some, including his ward manager, gave evidence that they thought that
asking the question might give a patient the idea of taking his life, though
evidence was given by the assistant director of nursing that this thinking
is not accordance with training or accepted practice.
One mental health nurse said that, although he would ask the suicide
question of a patient who appeared isolated or in low mood, he could not
ever remember asking that question, despite his work on a secure mental
health ward.
2. Resuscitation
The psychiatry doctor who attended the resuscitation in progress
(approximately seven minutes after Mr Abokar was discovered), found an
ambubag mask on Mr Abokar’s face, but no ambubag connected and no
person holding the mask.
The nurse who had been in charge of Mr Abokar’s airway said that she
had been giving him mouth to mouth resuscitation, though no other
witness in the room saw this. No explanation was provided as to why she
would have given mouth to mouth rather than use the ambubag present
(even if the ambubag was not connected to a flow of oxygen).
2
The nurse had left Mr Abokar in the middle of resuscitation, simply to go
out into the corridor and ascertain the whereabouts of the paramedic.
She said that she had left Mr Abokar’s airway in the care of another
member of staff, but she did not know who that person was, and all other
members of staff in the room denied that his airway was ever left in their
charge. She was out of the room for 50 seconds.
The paramedic attending Mr Abokar after resuscitation had been ongoing
for quite some minutes, said that Mr Abokar’s head was not tilted back
sufficiently, and the ambubag reservoir was not inflated because the
oxygen cylinder, whilst connected, was not switched on.
Neither of the paramedic’s observations was accepted by the nurse with
control of the airway, though he clearly has a great deal more experience
of resuscitation than she.
The nurse also said that a colleague, though she did not know who, had
connected the ambubag to the first oxygen cylinder; and then a
colleague, either the same colleague or a different one, she did not know,
had connected the ambubag to a second cylinder; though all other
members of staff in the room denied that they had done this.
It appears
that Mr Abokar’s ventilatory support was significantly
compromised by the way in which it was conducted. It was entirely
unclear what impact, if any, this had on Mr Abokar’s potential recovery,
though that would not necessarily be the case for another patient in a
similar position.
Matters already addressed
There were other issues regarding the resuscitation, and also the
availability of ligature points, that have already been addressed by the
trust and are already being shared with other hospitals at a national level.
6
ACTION SHOULD BE TAKEN
In my opinion, action should be taken to prevent future deaths and I
believe that you and your trust 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 28 January 2014. I, the coroner, may extend the
period.
3
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
I have sent a copy of my report to the following.
HHJ Peter Thornton QC, the Chief Coroner of England & Wales
Professor Dame Sally Davies, Chief Medical Officer for England
, sister of Abdullahi Abokar
Dr
Ms
Dr
staff nurse, Highgate Hospital
formerly of Highgate Hospital
, consultant anaesthetist, Whittington Hosp
I 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
interest. You may make
representations to me, the Senior Coroner, at the time of your response,
about the release or the publication of your response by the Chief
Coroner.
it useful or of
find
9
DATE SIGNED BY SENIOR CORONER
03.12.13
4
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.
REGULATION 28: PREVENTION OF FUTURE DEATHS REPORT - ABDULLAHI SHARIF ABOKAR RESPONSE TO THE CORONER, 31 JANUARY 2014 Response to Regulation 28: Prevention of Future Deaths report Abdullahi Sharif ABOKAR (died 21.06.12) Camden & Islington NHS Foundation Trust‟s (“the Trust”) response to the Prevention of Future Death report for Mr Abokar is set out below. The ward where the death took place, Coral ward, has been the subject of further clinical and quality scrutiny since the inquest. The matron at Highgate Mental Health Centre has raised further concerns about leadership and quality of practice on Coral Ward. As a consequence of the Prevention of Future Deaths report and our subsequent enquiries, we have adopted a “Rapid Improvement Plan” for Coral ward. The Rapid Improvement Plan process is used within the Trust when we are concerned that the quality and/or safety of a particular service is inconsistent with our standards. The Rapid Improvement Plan process establishes a governance process, resources and a timetable to improve the service. The oversight group, Chaired by our Chief Operating Officer has been formed to rigorously monitor the progress against the rapid improvement plan. The response below summarises relevant elements of the plan which will enable us to address the Regulation 28 report‟s concerns: Coroner’s Concern Detail Action 1. Asking the suicide question Several members of staff looking after him did not ask Mr Abokar if he had thoughts of taking his life. Some, including his ward manager, gave evidence that they thought that asking the question might give a patient the idea of taking his life, though evidence was given by the assistant director of nursing that this thinking is not accordance with training or The Trust has implemented the following plan to ensure patient safety through staff having competence and confidence in the assessment of suicidal risk in patients. The Trust expects all its clinical staff to regularly ask every patient about suicide, in terms of thoughts or plans and this issue is explored in clinical supervision and through regular monitoring of clinical standards. a) An intensive programme of work commenced on Coral ward on 13th January 2014, called the Rapid Improvement Plan. This accepted practice. One mental health nurse said that, although he would ask the suicide question of a patient who appeared isolated or in low mood, he could not ever that question, despite his work on a secure mental health ward. remember asking contains the following elements: i) A new „turnaround‟ nurse manager in place to lead the team. ii) All staff will be assessed against a schedule of core clinical competencies, developed by the deputy director of nursing. Staff demonstrating additional support or training needs will receive these with immediate effect. iii) From 27th January 2014 Coral ward will have the benefit of 2 days per week of Practice Development Nurse time. Practice Development Nurses will account to a new Nurse Manager who is leading Coral ward‟s turn around work. Practice Development Nurses are tasked with improving the quality of care delivered by clinical staff through: Enhancing their knowledge and skills. A focus on improving staff‟s ability to communicate, perform mental state examinations, write care plans, provide appropriate information to patients and to improve the overall quality of their interactions with patients. All clinical staff are required to undertake basic (Level 1) training in safeguarding. Further training at Level 2 will be provided to all Coral Ward staff by the Trust Safeguarding lead in February 2014. The aim of this is to enhance the knowledge of skills of this staff group in particular in protecting their patients from potential and actual risk from others. b) Investigation of the ward manager under the Trust disciplinary policy. 2 c) Monitoring of the capability of two members of staff to provide appropriate patient care specifically around risk assessment and management due to evidence presented by them in the Coroner‟s court, and through subsequent assessment of their skills by the matron of the Highgate Mental Health Centre. d) The Trust will commission Acute In-patient Suicide Prevention training from Kings College, London by March 2014 for all inpatient services. e) Led by the Director of Nursing, the Trust is revising its strategy for Risk Management. This will be completed by March 2014 and will risk outline expectations of staff competency, content of assessments and care planning, content of interactions between staff and patients and the ways in which these will be monitored to maintain consistent standards of all staff. f) All staff in our psychiatric intensive care unit, acute inpatient wards, crisis houses and community crisis teams will receive further training in use of a risk assessment and management system from 28th January 2014. This training will be completed 30th April 2014. 2. Resuscitation the The psychiatry doctor who attended (approximately in progress resuscitation seven minutes after Mr Abokar was discovered), found an ambubag mask on Mr Abokar‟s face, but no ambubag connected and no person holding the mask. The nurse who had been in charge of Mr Abokar‟s airway said that she had been giving a) A revised Trust Resuscitation Policy was approved by the Trust‟s Quality Committee in November 2013, containing changes in line with national guidance and also directly related to learning from this inquest‟s findings. b) The Director of Nursing has overall responsibility for policy development, implementation and ensuring CPR standards are 3 him mouth to mouth resuscitation, though no other witness in the room saw this. No explanation was provided as to why she would have given mouth to mouth rather than use the ambubag was not connected to a flow of oxygen). the ambubag present (even if upheld, as resuscitation lead for the Trust. c) Training in „in-hospital life support‟ has always been a mandatory requirement for ward staff. This will continue under the revised policy in line with national requirements. d) Due to the infrequent occurrences of CPR within mental health hospital settings, our inpatient units will now perform simulation exercises every 6 months to ensure staff get practice in performing CPR. The matron from each unit has responsibility for organising these, under the guidance of the Deputy Director of Nursing. The first such exercises will take place in April 2014.The exercises will be monitored through our committee structure. e) Management of the resuscitation scene will no longer be with the attending doctor, but with the most senior nurse on duty at the time. This will be the duty nurse or site matron who will have responsibility for coordinating staff actions, and handing over information to attending paramedics. Until the paramedic lead accepts responsibility, the duty nurse or site matron will maintain the lead for managing the resuscitation. f) Training in use of oxygen will now be provided by an independent company contracted to provide this for the Trust. This is a specialist Health and Safety firm. The Trust will ensure that live oxygen cylinders are provided for each training session for this purpose, which will enable staff undergoing training to familiarise themselves fully with the cylinder and how it functions, including the sound it makes when activated. The Deputy Director of Nursing has responsibility for organising this. The Trust will also recommend to the National Resuscitation Council that this should be a component of in-hospital Life support training, as it is not currently stipulated as 4 such in their 2013 guidance. g) The nurse identified as responsible for maintaining the airway during this inquest is being managed under the Trust‟s capability policy. 5
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