Simon Sankey

Date of report	27 Dec 2013
Reference	2013-0361
Deceased	Simon Sankey
Coroner	Mary Hassell
Coroner area	Inner North London
Category	Mental Health related deaths
Source	judiciary.uk record · original PDF
Responses published	2

The report

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. Mr Simon Barber, Chief Executive, 5 Boroughs Partnership NHS
Foundation Trust, Hollins Park House, Hollins Lane, Winwick,
Warrington, WA2 8WA.

CORONER

I am Alan Peter Walsh, Area Coroner for the Coroner Area of Manchester West

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.

INVESTIGATION and INQUEST

On 10" July 2013 I commenced an investigation into the death of Howard
Simon Sankey otherwise known at Howard Simon Gee, Aged 29 years, born on
the 12 December 1984.

The investigation concluded at the end of the Inquest on the 12" December
2013.

The medical cause of death was 1a) Suspension by Ligature.

The conclusion of the Inquest was Howard Simon Sankey took his own life.

CIRCUMSTANCES OF THE DEATH

previously resided a , Leigh and they had a son
EE Dorn in 2012.

The deceased was separated from [EEE who continued to reside atl
Leigh, and in July 2013 he was residing with his mother at

ES (='ct.

On the 4" July 2013 the deceased had stayed overnight at
Leigh and at or about 14:15 hours on that day he was found, having died,
suspended by a ligature attached to a ceiling metal support in the garage at the
address leaving a note indicating his intention to end his life.

The deceased had a volatile — with with whom he had

On the 1* July 2013 the deceased had attended his General Practitioner, Dr

at the Dr Alistair Partnership, Atherton with a fear that he had bi -
polar disorder and he described a long history of erratic mood swings and
impulsive behaviour. Dr §iireferrea the deceased to the Gateway and Advice
Service, Leigh which is also known as the Wigan Assessment Service
(hereinafter referred to as Gateway) based at Claire House Heaith Centre,
Phoenix Way, Lower Ince, Wigan. Drill used a form headed “Gateway and
Advice Service, Leigh Screening and Referral Form” to submit the form by fax.
In completing the form D made some mistakes, including the deceased’s
previous name of Howard Gee and the wrong address, but the contact
telephone numbers on the form were correct. The contact telephone numbers
referred to the deceased’s and his mother’s mobile telephone numbers. In the
risk factors section of the Form Dr stated “no home, living with mother as
a temporary measure. Please contact patient today via his mother’s mobile
phone.” The Form was sent to Gateway by Dr by fax on the 2" July 2013
at 08.35 hours.

Gateway is part of 5 Boroughs Partnership NHS Foundation Trust and is based
at Claire House Health Centre, Phoenix Way, Lower Ince, Wigan. It is a single
point of access into secondary mental health services providing specialist mental
health assessment, advice and signposting for adults suspected to be suffering
from moderate to severe mental health problems.

Gateway has four categories of urgency namely :-

1. Accident and Emergency Department - to be seen immediately.
2. Emergency ~ appointment will be offered within a maximum of 24 hours

of the referral.

3. Urgent — an appointment will be offered within a maximum of 72 hours
of the referral.

4. Routine — an appointment will be offered within 10 days of the referral.

The categorisation of a referral is done by an Administration Assistant with no
training or experience of risk assessment and the Assistant prepares the
referrals into hard copy files which are placed in piles relating to each category
for a Senior Nurse Practitioner to contact the service user. There is no sifting
procedure by the Senior Nurse Practitioner to prioritise individual cases within
each category and there is no immediate check or review of the categorisation
following the decision made by the Administration Assistant.

At the time of the referral relating to the deceased there was only one Senior
Nurse Practitioner on duty at any one time although on occasions there may
have an additional member of s duty in the team dealing with referrals.
Notwithstanding the fact that Dr| requested contact “today” the deceased
was categorised as a Routine referral and handed to the Senior Nurse
Practitioner as a Routine referral.

The procedure in relation to handling a referral is referred to in written
Operational Guidance, which provides that after receipt by Gateway, the
referral should be logged on to the OTTER system (Electronic Patient Record
Computer System) by the Administration Assistant stating the priority deemed
by the referrer, the priority allocated by the screening practitioner and the
clinical rationale for the allocated response time. The referral should be passed

to the Senior Nurse Practitioner within 30 minutes of it being logged on to the
system and the Senior Practitioner should review the information and/or carry
out a telephone screening with the referrer or individual referred in order to
make a reasonable assumption about the level of service priority. The evidence
at the Inquest was that the above procedure was not followed by Senior Nurse
Practitioners in relation to the deceased or any other referred cases.

In relation to the deceased the referral was entered on to the OTTER system at
10.00 hours on the 2" July 2013 and the referral was allocated to the Senior
Nurse Practitioner at 10.10 hours on the same date. The referral was not
reviewed by the Senior Nurse Practitioner and there was no attempt to carry out
a telephone screening with the referrer or the deceased until 19.36 hours on the
2™ July 2013. The OTTER system showed that the Senior Nurse Practitioner
acknowledged the referral at 19.34 hours and telephoned the deceased using
the deceased mobile telephone number at 19.36 hours. The Senior Nurse
Practitioner did not follow the instruction on the referral form to contact the
deceased via his mother’s mobile phone, which was correctly stated on the
referral form. There was no reply from the deceased’s mobile telephone but the
Senior Nurse Practitioner did not make any further telephone calls either to the
referrer or the mother’s mobile telephone and no further contact was attempted
by Gateway until the deceased himself telephoned Gateway at 16.00 hours on
the 3" July 2013.

When the deceased telephoned Gateway at 16.00 hours on the 3 July 2013 he
spoke to a Senior Nurse Practitioner who reassessed his case as an Urgent case
and he was given an appointment to attend Claire House Health Centre to see a
Senior Nurse Practitioner on the 5” July 2013 at 11.30 hours. The evidence at
the Inquest indicated that the deceased had been offered an appointment on
the 4" July 2013 but the deceased wanted to speak to his mother prior to the
appointment and he agreed the appointment on the 5" July 2013.

In the meantime the deceased died on the 4" July 2013 prior to the allocated
appointment.

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) During the Inquest evidence was heard that :-

i) The categorisation and allocation as between Emergency, Urgent
and Routine referrals is done by an Administration Assistant who
is not qualified nor trained to carry out such duties. The
Administration Assistant enters the service user on to the OTTER
system with the category of urgency and the hard copy file is
delivered to the Senior Nurse Practitioner including details of the

referral which should be acknowledged by the Senior Nurse

Practitioner within 30 minutes of receipt.

ii) There is no review of the hard copy file, the referral form or the
entry on the electronic patient record to enable a review of the
category of urgency assessed by the Administration Assistant.
Furthermore there is no action taken by the Senior Nurse
Practitioner to prioritise referrals within each category to identify
the more urgent cases within each category to ensure contact
with the service user within the most appropriate time for that
service user.

ii) The OTTER system provides a list of all referrals in date and time
order identifying the category of urgency but the list is not
available to each Senior Nurse Practitioner and the list is only
available to the Manager of the team.

At the time of the referral relating to the deceased only one
Senior Nurse Practitioner was on duty at any one time dealing
with all referrals. The Gateway Team has 16 members who are
engaged in different duties and many of the duties are out of the
office. The Senior Nurse Practitioner on duty deals with all
written or faxed referrals, including Emergency, Urgent and
Routine referrals together with all telephone referrals and other
request to Gateway either by telephone or by personal
attendance. There are 500 to 600 recorded referrals to Gateway
each month so that there are 25 to 30 referrals each working
day.

Evidence was given at the Inquest that a new team has been
established at the Hospital to deal with referrals through the
Accident and Emergency Department at the Hospital and an
additional member of staff now works with the Senior Nurse
Practitioner in relation to other referrals but there is still a very
high and unpredictable workload for the Senior Nurse Practitioner
each day.

v) When a service user is not contacted or when an attempt to
contact has failed the hard copy file is put into a file tray to be
picked up whenever by another Senior Nurse Practitioner. There
is no system of reviewing the none contact referrals within an
appropriate and reasonable time. There is a handover from one
Senior Nurse Practitioner to another Senior Nurse Practitioner at
the end of each shift and there is a meeting each morning to
discuss outstanding cases but there is no system to ensure that
all outstanding cases are considered at the morning meeting and
there is no re-prioritisation of the cases to ensure that all service
users are contacted within an appropriate and reasonable period.
In the case of the deceased his referral was not discussed at the
morning meeting on the 3 July 2013 after contact had failed at
19.36 the previous evening and his referral had not been
reviewed by any Practitioner prior to his telephone call at 16.00
hours on the 3” July 2013.

vi) The evidence at the Inquest revealed in effective management of
the Team to co-ordinate and allocate resources to deal with an

unpredictable number of referrals each day. The list of referrals
in date and time order prepared by the computer system is only
accessible to the Team Manager who did not appear to share the
information on the list with Senior Nurse Practitioners to ensure
that any delays in contact with a service user would be actioned
and reviewed taking account of the date and time of the referral.

2. I have concerns with regard to the 5 Boroughs Partnership NHS
Foundation Trust, particularly the Gateway Team, in relation to:

i) The categorisation and allocation of referrals by an
Administration Assistant who has insufficient knowledge
and who is not trained to make such important decisions

The prioritisation of each referral to ensure contact within an
appropriate and reasonable period of time having regard to the
urgency and merits of each referral.

ili) The system to ensure contact with service users within
appropriate time periods particularly when the initial contact with
the service user has failed.

iv) The systems and procedures to ensure contact with service users
within appropriate time periods following receipt of the referral
and the fact that the computerised list of referrals in date and
time order is not available to Senior Nurse Practitioners.

The ineffectiveness of handovers as between Senior Nurse
Practitioners and the ineffectiveness of the morning meetings to
review referrals particularly those referrals where the initial
contact with the service user has failed.

vi) The staffing levels on each shift, particularly having regard to a
large and unpredictable volume of referrals each day.

vil) The ineffective management of the team as a whole and in
particular Senior Nurse Practitioners to co-ordinate and allocate
resources to deal with the large volume of referrals within the
appropriate time period.

viii) The training of staff in relation to the written Operational
Guidance, which was not followed by any of the Senior Nurse
Practitioners who gave evidence at the Inquest, to ensure that
referrals are dealt with and service users are seen within
appropriate time periods.

ACTION SHOULD BE TAKEN

In my opinion urgent action should be taken to prevent future deaths and I
believe you and/or your organisation have the power to take such action.

YOUR RESPONSE

You are under a duty to respond to this report within 56 days of the date of this
report, namely by 21% February 2014. I, the Area 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

1. | mother of Howard Simon Sanke
SE Go in

2. EH the former Partner and Mother of
2012, the son of Howard Simon Sankey

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 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.

Dated Signed (}

27" December 2013 Alan Peter Walsh

Also filed under 2013-0361: Timothy-Clayton-2013-0558_Redacted.pdf

Regulation 28: Prevention of Future Deaths report

Timothy Patrick CLAYTON (died 10.11.13)

THIS REPORT IS BEING SENT TO:

1. Mr Ian Learmonth QPM

Chief Constable of Kent Police
Kent Police Headquarters
Sutton Road
Maidstone
Kent ME15 9BZ

CORONER

I am: Coroner ME Hassell
Senior Coroner
Inner North London
St Pancras Coroner’s Court
Camley Street
London N1C 4PP

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.

INVESTIGATION and INQUEST

Yesterday, the death of Timothy Patrick Clayton was reported to me. I am
still at the pre investigation stage of my inquiries, but I anticipate that I
shall open an inquest touching Mr Clayton’s death.

CIRCUMSTANCES OF THE DEATH

Just before 1pm yesterday (Sunday, 10 November 2013), one of my
coroner’s officers alerted me to the death of Timothy Clayton. He told me
that Mr Clayton had been brought to the Royal London Hospital by
helicopter from Kent with a severe head injury, and that brain stem death
tests had been conducted a little over half an hour before, although Mr
Clayton was still being supported medically.

Police enquiries had revealed CCTV of Mr Clayton being kicked to the
head and body in a sustained attack. My officer,
, said that
Mr Clayton’s family had given permission for organ donation and so I was
being contacted in this respect.

When a death is reportable to HM Coroner, the coroner has lawful control
of the body, and so his or her permission is sought before any organ
donation. The coroner does not give consent to the donation, only the
individual himself by way of advance directive, or his family consulted at
the time of death, can do that. However, after consent is given, the
coroner may then raise an objection to donation. If the coroner objects to
donation, the donation cannot take place.

Mindful of the ongoing police investigation, I asked that the Kent Police
senior investigating officer (SIO) telephone me to discuss the proposed
donation. A short while later, the detective chief inspector in charge of
the investigation, Paul Fotheringham, telephoned me. He gave me an
account of the investigation so far, and told me that Kent Police objected
to organ donation going ahead, on the basis that this would compromise
the criminal investigation.

We talked through the matter at some length. He was concerned that the
organs it was proposed to donate (lungs, kidneys, small bowel and
pancreas) might be diseased and the suggestion be made that this had
contributed to death. I put it to him that if they were diseased then they
would not be suitable for transplant. He was further concerned that these
organs might have been injured by the attack. Removal of them would
therefore deny us the ability to determine the medical cause of death. I
explained that the understanding that I had gained, was that Mr Clayton
had died from a traumatic head injury, and therefore the organs in
question would not take us any further forward in determining medical
cause of death.

that we work

that I saw no reason to object to the donation. I
I told
suggested
facilitate donation without
compromise to the homicide investigation. I offered my assistance, for
example, I authorised the taking of photographs before donation. The
detective chief inspector remained very firmly opposed to donation.

together,

I suggested that he contact the forensic pathologist who was to perform
the post mortem examination and then, having spoken to him or her, ask
that pathologist to telephone me. I asked
to ascertain
from Mr Clayton’s treating clinicians the nature and extent of the head
injury.

A little while later, I was telephoned by
pathologist on call this weekend.
donation.
with it the potential to lose some evidence, and he advised against it.

, consultant forensic
and I discussed the proposed
s view was that going ahead with the donation carried

gave me a thoughtful analysis, suggesting that if the organs
were donated, we might not discover whether any of these organs had
sustained contusions in the kicking that was apparently discernible on
CCTV. I asked him how much further forward the discovery of a
contusion (that presumably did not significantly affect function or the
organs would not be suitable for donation) would really take us, given the
nature of the CCTV (showing one person kicking Mr Clayton repeatedly)
and most especially given that cause of death appeared to be a traumatic
head injury.

He felt that this was really a legal question, and also explained that he did
not have any detailed information on the clinicians’ view of medical cause
of death or the extent of Mr Clayton’s head injury.

Having gone through the matter together carefully,
remained of
the view that there was a risk of losing some evidence by allowing
donation but, in response to my direct question as to whether he viewed
allowing donation to go ahead as foolhardy, he replied that he did not.
He told me that he recognised that this was a balancing act, and that the
decision was mine.

The decision before me seemed a difficult one. I was inclined towards
donation, but I thought it would be helpful to articulate my thoughts by
running through the scenario with another senior coroner, and so I
telephoned a colleague in a different part of the country. I wanted to be
sure that I had considered all angles before coming to my conclusion.
Again, we spoke at some length.

He re-emphasised that his duty
I then spoke again to
was to ensure an effective investigation/prosecution, and he once again
voiced his objection to donation. I requested that he ask Mr Clayton’s
treating consultant to telephone me.

I was then called by
is a consultant in critical
care and renal medicine, and he explained that he was responsible for Mr
Clayton’s care. He told me that there was absolutely no doubt in his mind
about the cause of Mr Clayton’s death. This was an unsurvivable
traumatic head injury. He said that the head injury was massive, and that
he was not sure when he had seen a head injury of this magnitude, in
spite of his role at the trauma centre of the Royal London Hospital.

I thought very carefully about all the evidence that had been presented to
once more
me and I made my decision. I telephoned
and told him that I would not raise any objection to donation.

Once again I went through my responsibilities with him, re-iterating that I
wanted to guard against the failure of a proper conviction or a proper
acquittal because of any compromise by organ donation. I told him that,

although I completely took
point that some evidential detail
might be lost by organ donation, I did not believe that this would impact
upon the proper exploration/prosecution of any person potentially
responsible for Mr Clayton’s death.

I asked that the following steps be taken:

1. an immediate whole body scan;
2. photographs before organ retrieval;
3. the forensic pathologist to be offered the opportunity to be present

at organ retrieval;

4. the transplant surgeon(s) to document all findings at retrieval.

I telephoned my coroner’s officer and explained my decision. My
involvement in the matter that day concluded at around 4pm. However, I
received a telephone call at 5.30pm from
introduced herself as the specialist nurse for organ donation with
responsibility for this matter. She had spent much of the day working with
Mr Clayton’s family on the potential donation.

She told me that, quite literally as Mr Clayton’s family were leaving the
hospital, the Kent Police family liaison officer (FLO) stopped them and
told them that, if they allowed the organ donation for which they had
already given their written consent to go ahead, the person who had killed
Mr Clayton might not be convicted (I paraphrase). Apparently the FLO
had been instructed to have this conversation by

Mr Clayton’s family had hoped that some good could come from Mr
Clayton’s very untimely death. They had firmly indicated that they wanted
organ donation to go ahead, and were apparently devastated at the news
that donation would compromise the homicide investigation. They felt
they had no choice but to withdraw their consent to organ donation.

The organ donation did not, therefore, go ahead.

CORONER’S CONCERNS

My inquiries have 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. Kent Police approached Mr Clayton’s family to consider a decision
that is, by law, conferred upon HM Coroner. This action placed Mr
Clayton’s family in desperately difficult and desperately painful
position. Having already given their consent to donation, they

were asked to go back on this and to make a further decision
based upon the likely success of prosecution of Mr Clayton’s killer,
rather
trained,
experienced, dispassionate judge – the coroner.

this separate decision resting with a

than

This must have added horribly to their distress, and it was a wholly
improper burden to place upon them.

2. As the coroner with responsibility for this matter, I did not make the
decision not to object to organ donation on a whim. I did so after a
great deal of discussion and thought.

Though I am a senior coroner with particular experience of organ
donation, a subject on which I have lectured to doctors, nurses and
police officers on several occasions, I nevertheless sought out a
senior coroner colleague on a Sunday afternoon, to try to ensure
that I had not missed anything.

I was transparent in my thinking, I listened carefully to all advice,
including that of the senior investigating officer, and I gave detailed
reasons for my decision. Nevertheless, that police officer sought
to subvert my judicial decision.

He did not ask a more senior police officer to contact me to
discuss the matter further. He did not seek to challenge in a
higher court. Instead, he effectively reversed the decision made
by a judge because he preferred his own view of the matter, and
he did this by bringing pressure to bear on a grieving family.

In short, a police officer has subverted the rule of law.

You may be surprised that I write to you about this matter by way of a
prevention of future death (PFD) report. I do so because in this instance,
six organs were lost to their potential recipients - two lungs, two kidneys,
a small bowel and a pancreas. Six organs represents six lives.

ACTION SHOULD BE TAKEN

In my opinion, action should be taken to prevent future deaths and I
believe that you Kent Police have the power to take such action.

YOUR RESPONSE

You are under a duty to respond to this report within 56 days of the date
of this report, namely by 7 January 2014. I, 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 following.

 HHJ Peter Thornton QC, Chief Coroner of England & Wales
, Chair of the IPCC


(Independent Police Complaints Commission)

, Kent Police and Crime Commissioner


 Detective Chief Inspector





, consultant forensic pathologist

, regional lead for organ donation
, specialist nurse for organ donation

, consultant in critical care & renal medicine,

, Kent Police

Royal London Hospital

I have not sent a copy to Mr Clayton’s family, because that seems
inappropriate only a day after Mr Clayton’s death. I appreciate that
immediate family members are properly interested persons and must, of
course, see a copy of my report, but I should like to give them a little time
to come to terms with their loss first.

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
interest. You may make
he believes may
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

DATE SIGNED BY SENIOR CORONER

11.11.13

Responses

2 responses 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.

Response from 5 Boroughs Partnership (PDF)

RECEIVED
24 FEB 2014

255 SF 99-29 Wy 20 we ae ae om,

| 5 Boroughs Partnership AVEKY

NHS Foundation Trust

Our Ref: SB/SA Chief Executive’s Office

Hollins Park House

Your Ref: APW/GEB/H.S-Sankey Winwick

Warrington

Cheshire

20 February 2014 WA2 8WA

Tel: 01925 664001

Mr A P Walsh Fax: 01925 664052
HM Coroner Email:

Great Manchester (West)
HM Coroners Court
Paderborn House

Civic Centre

Howell Croft North
Bolton

BL1 1JW

Dear Mr Walsh
Re: Howard Simon Sankey - deceased

Thank you for your fetter dated 27 December 2013 with regards your findings into the
death of Mr Howard Simon Sankey and the directions given under Regulations 28
and 29 of the Coroners (Investigations) Regulations 2013. | would like to advise you
of the actions the Trust has taken both since the inquest and since receiving your
letter.

Your letter specifically refers to your concerns about the management of referrals
received within the Trust's Assessment Team for Wigan and the apparent
ineffectiveness of the team in dealing with referrals appropriately; this included the
numbers of referrals being received by the Team, concerns regarding the staffing
levels and the unpredictable nature of the volume of referrals.

You were particularly concerned with whom within the team identified the priority for
the referral and whether this was the role of an administrative team member. You
also sought assurances about whether the team could action all referrals in line with
agreed timescales, as detailed in our Assessment Service Operational Guidance.
You were also concerned to know what actions were taken by Practitioners when a
service user was not contactable and how this was handed over to the following shift
to ensure appropriate action was taken.

Taking your points in turn, | can confirm the Trust have completed the following:

Chief Executive: Mr. Simon J. Barber
Chairman: Mr. Bernard Pilkington
Trust Headquarters, Hollins Park House, Hollins Lane, Winwick, Warrington, WA2 8WA
Mini Com Number 01925 664094

Matters of concern:

It is the referrer and not an administrator who categorises referrals. A system
is in place whereby administration staff place referrals in an appropriate tray
based on the referral priority provided by the referrer, who is usually a general
practitioner. Where no priority has been identified by the referrer this is now
brought to the immediate attention of the senior nurse practitioner on duty who
will review the referral and assign the appropriate clinical priority within a
maximum of 30 minutes of receipt.

The referral priority is identified on the referral form initially by the referrer.
This is placed in the appropriate tray by administrative staff as detailed above.
The senior nurse practitioner on duty is alerted to the receipt of the referral
and takes action to clinically review the information provided in order to
allocate an appropriate response time in accordance with the agreed
operational guidance. This action occurs within a maximum of 30 minutes of
receipt of referral. A number of options are available to the duty staff upon
review of the referral. This includes allocation of an emergency assessment if
deemed appropriate or a response time within the urgent or routine
categories. The electronic patient information system, Otter, is available to all
staff both clinical and administrative.

The service user information system, Otter, already records the date and time
of referral in addition to the referred and assigned priority. This information is
available to all staff in the assessment team and | apologise if this was not
made clear during the course of the inquest.

The work of the assessment team can be unpredictable due to the unplanned
nature of referrals. | can confirm that whilst at the time of the incident, the
team had gaps in staffing due to sickness and vacancies; the team is now fully
established. Sickness continues to be proactively managed at a local level and
monitored across the entire business stream in line with Trust policy. Staff
work to a rota that ensures maximum coverage across the 24 hour period.

There is a system in place where the referral/case notes will stay in the
referral tray until at least three telephone calls have been made to the service
user within a maximum of a 24 hour time frame. The purpose of the telephone
calls to the service user is to enable further information gathering to assist with
the prioritisation of the referral and to arrange a mutually agreed appointment
date and time. A further system is in place which indicates that after this time,
a face to face unplanned visit will be arranged for urgent referrals which will
take place at the address provided by the referrer.

In the case of referrals considered to be of a routine nature, they are
discussed the next day in the morning meeting and a decision taken as to
whether the cases need to be reprioritised. A multi-disciplinary team decision
is taken on the next action required, which can include an increase in referral
priority or further discussions with the referrer on the appropriate course of
action.

2

Chief Executive: Mr. Simon J. Barber ait M00,
Chairman: Mr. Bernard Pilkington 5 fe
Trust Headquarters, Hollins Park House, Hollins Lane, Winwick, Warrington, WA2 8WA te

Mini Com Number 01925 664094 Misa

ef

é
é

Vi. A formal written handover takes place at the start of each shift. As per
number V above, the morning meeting reviews all cases for the previous day
where no contact has been made and decides on an appropriate course of
action. This is recorded on the Otter information system which is available to
all staff and as previously stated | apologise if this was not made clear to you
during the course of the inquest.

2 | have concerns with regard to the 5 Boroughs Partnership NHS Foundation
Trust, particularly the Gateway Team, in relation to:

I. Please refer to 1. | above.

ll. Please refer to 1. Il above.
lll. Please refer to 1. V above.
IV. Please refer to 1. Ill above.
V. Please refer to 1. V above.

VI. Please refer to 1. IV above. In addition, all vacancies within the assessment
service have been recruited to. There is no waiting list for referrals to be seen.

Vil. The Trust are currently undertaking a review of the entire Acute Care Pathway
(ACP) which includes a review of staffing levels and skill mix across all teams
and the effectiveness of pathways between services. This is due to be
reported at the end of February 2014. The team manager receives regular
management supervision where the concerns you have raised have been
discussed and action taken.

VIIL. Training in the form of ‘lessons learned’ took place on 22 January 2014 and
included an update of guidance and systems currently in place within the
team. This has been cascaded across the other assessment teams and will
be shared at the Quality and Governance Meeting in February 2014.

| can assure you that as a Trust we take the management of referrals very seriously
and | can confirm that the management of referrals within the Assessment Team has
been reviewed. Whilst it was never the role of the administrative staff to assign a
referral priority, the assessment team does has a robust system in place to ensure all
referrals accepted by the team, are reviewed by a senior clinical member of staff
without any undue delay. A system has been introduced whereby the team have a
daily recorded morning meeting in which referrals are identified and actions or
responsibilities for the shift are delegated.

In terms of wider learning from serious untoward incidents, the three Assessment
Teams managed by the Trust meet together in formal minuted meetings. This forum
is used as a vehicle to learn lessons and share good practice. All changes to
systems have been discussed and shared with the steering group and the
implementation of the changes is monitored by the focal management teams. This is

3

Chief Executive: Mr. Simon J. Barber nt Ne,
Chairman: Mr. Bernard Pilkington ERA) e
Trust Headquarters, Hollins Park House, Hollins Lane, Winwick, Warrington, WA2 8WA oA ¢

Mini Com Number 01925 664094 sage

to ensure consistency across the teams and that any changes made support and
link-in with the pathways into other services and teams.

Further to the Serious Untoward Incident (SUI) Report being completed, an action
plan was developed by the local Business Manager for the Trust to deliver, all of
which linked into the recommendations set out by yourself. | can also confirm that all
the recommendations made in relation to this case, have now been completed.

If | can be of any further assistance or you require further information about the steps
we have taken, please do not hesitate to contact me.

Yours sincerely

S Baer

Simon Barber
Chief Executive Officer

4
Chief Executive: Mr. Simon J. Barber aCe
Chairman: Mr. Bernard Pilkington FOO s
Trust Headquarters, Hollins Park House, Hollins Lane, Winwick, Warrington, WA2 8WA PA <

Mini Com Number 01925 664094 Sage

Response from Respondent Not Named (PDF)

Ian Learmonth QPM
Chief Constable

Direct Line: 01622 652003
Fax: 01622 652009

24th December 2013

Coroner M.E. Hassell
Senior Coroner
Inner North London
St Pancras Coroner’s Court
Camley Street
LONDON
N1C 400

Dear Madam,

I refer to your Regulation 28 Prevention of Future Deaths Report dated the 11 November
2013 concerning Timothy Patrick Clayton deceased and this letter serves as my response
in accordance with Regulation 29.

The Coroners and Justice Act 2009 replaced Rule 43 Reports with Reports on Action to
Prevent Future Deaths (PFD) under paragraph 7 Schedule 5 of that Act and Regulations 28
and 29 of the Coroners (Investigations) Regulations 2013. It is accepted that Coroners
have a duty not only to determine how an individual came by their death but also where
appropriate to report about that death with a view to preventing future deaths.

I am aware that normally a PFD report will be made after the conclusion of an Inquest.
However, a report can be made before an Inquest is heard so long as there has been
compliance with Regulation 28(3) and that will only be when the Coroner has considered
all of the documents, evidence and information that in the opinion in the Coroner is
relevant to the investigation. It is with this condition in mind that I suggest that that
criteria perhaps has not been met in this particular referral.

The report from the Coroner states the concerns that there is a risk that future deaths will
occur unless action is taken by Kent Police and that it is the Coroner's statutory duty to
report to me. The reference to the use of a PFD report is due to the perceived belief that
6 transplant organs were lost to potential recipients and that 6 organs represents 6 lives.
This PFD report concerns the issue therefore of organ donation from Timothy Clayton, a
45 year old homeless male who was a homicide victim. The circumstances concerning his
death thereby being a live criminal investigation. Following receipt of the PFD report,
however, a formal review has been commissioned and completed into the circumstances
that led to the report being issued. The review has thoroughly considered the
circumstances and the Coroner's concerns and is therefore appended hereto.

Kent Police : Form No. 3058b rev 9/05 v1.21

In accordance with the requirements of Regulation 29, I now write to confirm that all
Senior Investigating Officers in Kent Police and Essex Police have been reminded of the
guidance contained within the Journal of Homicide and Major Incident Investigation
published by the National Policing Improvement Agency. All Senior Investigating Officers
are to be advised that any challenge to a decision by HM Coroner is through the Courts
processes.

An urgent review is to be conducted to consider the number and availability of family
liaison officers to ensure suitably trained staff are available for deployment when required
in homicide investigations. This will ensure that families are in possession of full and
appropriate information at all times.

The circumstances that arose in this particular case will also be included into future Senior
Detective training and has been drawn to the attention of senior personnel in the
Association of Chief Police Officers Homicide Working Group for national consideration.
What is also of note, however, is that no one has been provided with either the original or
a copy of Mr Clayton's organ donation card, despite this appearing to have been the
catalyst for the consent being sought from the family. The family had not requested the
consideration of organ donation.

Despite the Coroner's assertion that 6 deaths were preventable if the organ donation had
been completed, in fact only the kidneys were potentially viable but as Mr Clayton was a
known homeless alcoholic, the viability of these organs for successful transplantation is
therefore unknown. The use of a report in accordance with Regulation 28 by the Coroner
is therefore questionable.

There is still considerable distress being experienced by the family of Mr Clayton as his
body has not been transferred to Kent which has caused an additional burden on them.
In accordance with the provisions of Regulation 29(8)(b) of The Coroners (Investigations)
Regulations 2013 I would request that the review document appended to this letter is not
disclosed for publication as it contains third party information which does not have the
consent for publication and is provided to the Coroner and the Chief Coroner in response
to the Regulation 28 PFD report.

Yours sincerely

Ian Learmonth
Chief Constable

Kent Police : Form No. 3058b rev 9/05 v1.21

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