Prevention of Future Deaths reports · 2013
Regulation 28 report to prevent future deaths, reference 2013-0371, written 18 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 | 18 Dec 2013 |
|---|---|
| Reference | 2013-0371 |
| Deceased | Christine Williamson |
| Coroner | John Ellery |
| Coroner area | Shropshire, Telford & Wrekin |
| Category | Other related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 3 |
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.
LH¥———__— T REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT JS BEING SENT TO: 1. Managing Director Telford & Wrekin Borough Council Telford & Wrekin Council, Addenbrooke House, ironmasters Way, Telford TF3 4NT 2 Assistant Chief Constable West Mercia Constabulary West Mercia Police Head Quarters, Hindlip Hall, PO Box 55, Worcester WR3 8SP i- South Staffordshire & Shropshire Health Foundation Trust Trust Headquarters, St. George's Hospital, Corporation Street, Stafford ST16 3SR 4 EE. Telford & Wrekin Clinical Commissioning Group Telford and Wrekin CCG, NHS Telford and Wrekin, Halesfield 6, Halesfield, Telford, TF7 4BF 1 ~~ | CORONER (am John Penhale ELLERY, Senior Coroner, for the coroner area of Shropshire, Telford & Wrekin 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. 3 INVESTIGATION and INQUEST On the 13" November 2012 ! commenced an investigation into the death of Christine Ann WILLIAMSON aged 62 years. The investigation concluded in an inquest on the 16" December 2013. The conclusion of the inquest was ‘The deceased died from a physical assault by her husband who by reason of his lack of mental capacity was unaware of his actions or its consequences. If earlier action had been taken the deceased may have been protected and her death was preventable’. The medical cause of death was: fa Subdural Haematoma following mild blunt head trauma It Warfin therapy for recurrent deep vein thrombosis 4 “| CIRCUMSTANCES OF THE DEATH Mrs Williamson was 62 years of age when she died following an assault upon her by her husband who was suffering from advanced onset of Alzheimer’s dementia and was unaware of his actions or its consequences. The assault on the 18” October 2012 was the last of 5 recorded assaults between the 6" December 2011 and the 18" October 2012. —— 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) A referral and assessment should have been made that the deceased was a Vulnerable Adult at risk from her husband. Such a referral and assessment could have been made before or after Apri! 2012, but most notably on or around the 2" - 4** April 2012 when the deceased’s GP made a direct referral to social services. This should have led to an assessment as a Vulnerable Adult but if not as the victim of domestic violence. (2} Had such an earlier assessment as a Vulnerable Adult been made then discussions would have taken place with all concerned with everyone having significant information sharing it with others. This would have increased the likelihood that preventative measures would have been put in place with the deceased being better or fully informed as to the increased risk she was putting herseif in by continuing to live with her husband whose condition was deteriorating. The best illustration of this lack of shared information is that the evidence given at the Inquest when all relevant witnesses were present, should have taken place in a meeting before the situation became critical. (3) An independent domestic homicide review has been undertaken and the author of the report gave evidence at the inquest including authors or representatives of the relevant individual management reviews. Recommendations were made which | endorse. | __ 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you or 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 12" February 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. ——|. 8 COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the following interested Persons: a :., PY — Independent Overview Author i Service Delivery Manager, Cohesion, Darby House, s* Floor, Lawn Central, Telford TF3 4LE The Chief Executive - West Midlands Ambulance Service | Trust Headquarters, Millennium Point, Waterfront Business Park, Waterfront Way, Brierley Hill, DYS 1LX — GP Charlton Medical Practice, Lion Street, Oakengates, Telford TF2 6AQ Superintendent For Telford & Wrekin Safeguarding Board Malinsgate Police Station, Malinsgate, Telford, TF3 4HW 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 your response by the Chief Coroner. a 18" December 2013 Jofin Penhald Ellery
3 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.
- 5 FEB 2018 INHS| . Telford and Wrekin Clinical Commissioning Group Halesfield 6 Telford Shropshire TF7 4BF ce Direct Line: 4th February 2014 Your Ref: JPE/EJW Mr J P Ellery Senior Coroner H.M. Coroner’s Service 3rd Floor Guildhall Frankwell Quay Shrewsbury SY3 8HQ Dear Mr Ellery, Re: Christine Ann WILLIAMSON deceased Inquest: Telford Register Office, 16th December 2013 at 10am Report to prevent future deaths Thank you for your letter of the 18th December 2013 under Regulation 28 (Report to Prevent Future Deaths) of the Coroners (Investigations) Regulations 2013. As you will be aware, the Clinical Commission Group actively participated in the Domestic Homicide_Review_ commissioned by Telford & Wrekin Safer Community Partnership led by J within the review are 8 recommendations for future learning and action by all agencies involved in Mrs Williamson’s care. This Clinical Commission Group has taken this very seriously and has agreed to work with all agencies to prevent future deaths. As NHS England now commission Primary Care Service the CCG is working with colleagues to address the recommendations. The actions we have taken are as follows: 1) The Adult Safeguarding Policy and Thresholds has been recirculated to all GP Practices in Telford & Wrekin to raise awareness of this guidance. 2) Domestic abuse leaflets and guidance has been circulated to all GP Practices. TAKING CARE OF TELFORD AND WREKIN Every patient experience matters - Every clinician is involved 3) An education and training event for all Telford & Wrekin GPs and Practice Nurses will be funded and delivered with a focus on safeguarding requirements and domestic abuse. | have written to all GPs to request full attendance as far as possible. This event is part of the CCG’s Protected Learning Time Programme and will be delivered on 14th May. The training will be multi agency and we have invited the Domestic Abuse Team to present to the attendees ensuring that Royal College of General Practitioner's Guidance is fully referenced in accordance with the DHR recommendations. In addition, the CCG Lead Nurse for Adult Safeguarding has established a link with the Admiral Nurses to ensure that referrals figures are monitored. The Admiral Nurses will be invited to the education event to talk to GPs and Practice Nurses about their service, therefore promoting improved understanding for future patients. Furthermore, the CCG Safeguarding Team has a programme of audit for primary care providers in relation to safeguarding compliance, and this year’s review is currently underway. In order to address future issues around the growing prevalence of dementia the CCG has in place a dementia strategy which focuses on how provision of health services will be delivered. The plan is for a report on all recommendations from the domestic homicide review to be discussed at the Safeguarding Adults Board in June and the CCG Executive Nurse is a member of this Board. This safeguarding is regularly discussed with the CCG and its governing body I trust this gives the necessary level of assurance and commitment in this matter. Yours sincerely Chair of Telford and Wrekin Clinical Commissioning Group TAKING CARE OF TELFORD AND WREKIN Every patient experience matters - Every clinician is involved
a.co-operative council 4.4 FEB 2016 Telford & Wrekin Richard Partington Managing Director Addenbrooke House Mr JP Ellery Ironmasters Way Senior Coroner for the Shropshire, lem Telford & Wrekin area HM Coroner’s Service The Guildhall (3 Floor) Frankwell Quay Shrewsbury SY3 8HQ Contact: Telephone: Fax: Your Ref: Our Ref: RP/CoronerCAW Date: 7" February 2014 Dear Mr Ellery Re: Christine Ann WILLIAMSON (deceased) Inquest at Telford Registry Office on 16° December 2013 The Council’s Action Plan following Regulation 28 report, to prevent future deaths | refer to your letter of 18" December 2013. Following the above Inquest and the Council's receipt of your Report under Regulation 28, we have compiled a plan of action, which is submitted to you as directed, along with this letter. The planned actions, m j already well under way to implementation, build upon those recommended by in his Domestic Homicide Review report, which was available to the Inquest. The plan was drafted by senior representatives of the Council’s Adult Assessment and Case Management, Adult Safeguarding and Community Cohesion services, and endorsed at a meeting of the Senior Management Team on Monday 3” February 2014. Going forward, it has been agreed that the implementation of the action plan will be formally monitored by the Safeguarding Adults Board for Shropshire and Telford & Wrekin, in pursuance of its remit as the body which brings together all the organisations within the local adult safeguarding partnership. | trust that this meets with your approval. Yours sincerely visit us @ www.telford.gov.uk * | foliow us at www.twitter.com/telfordwrekin or www.facebook.com/telfordwrekin COUNCIL
Protective Services Report Title: Coroner Ellery’s letter — Christine WILLIAMSON (deceased) Prepared by: a /Detective Chief Inspector PVP Introduction This report seeks fo provide a detailed response to Coroner Ellery’s letter to West Mercia Police dated 18.12.13. West Mercia has a duty to respond by 12.02.14, under paragraph 7, schedule 5 of the Coroners & Justice Act 2009 and regulations 28 & 29 of Coroners (Investigations) Regulations 2013. The inquest concerning Mrs Williamson commenced on 13" November 2012 and concluded on 16" December 2013. The conclusion of the inquest was ‘the deceased died from a physical assault from her husband who by reason of his lack of mental capacity was unaware of his actions or its consequences. If earlier action had been taken the deceased may have been protected and her death preventable’, Background Information Mrs Williamson was 62 years old when she died on 31* October 2012, following an assault upon her by her husband who was suffering from advanced onset of Alzheimer’s dementia. The medical cause of death was determined as subdural haematoma following mild blunt head trauma. a... unaware of his actions and was removed from the family home on October 2012 following the incident. He was admitted to a local Psychiatric Unit and was subsequently sectioned under Section 3 of the Mental Health Act 1983. In September 2013, the Crown Pros i i ade the decision that no further action would be taken agains due to his medical condition. Plans are being made to move him to a secure hospital. Due to the circumstances surrounding this incident Telford and Wrekin Community Safety Partnership di Domestic Homicide Review (DHR) appropriate and appointed as. the independent chair. DHR The police Independent Management Review (IMR) was conducted by the Major Crime Review Team (MCRT). It was established that West Mercia Police had three contacts regarding the Williamson family between July and October 2012. Contact 1 - 8" Jury 2012 Police received a call from Shropdoc (out of hours GP) who were attending the address following a report of an assault, requesting a police escort, Intelligence checks were conducted with no risk factors identified. As a result the decision was taken in conjunction with Shropdoc not to deploy Officers to the incident as it was known that there was a dementia suffer at the address and attendance may aggravate the situation. Contact 2 ~ 19" August 2012 Police received a call from a neighbour reporting that Screaming and ting could be heard from the address. Staff attended and established that! aa was a former police staff member and made enquires to ascertain whether WMP occupational health would be able to offer any assistance. A vulnerable adult incident was submitted but no DASH risk assessment. The rt highlighted the violence suffered by Mrs Williamson; it recorded her ongoing medical complaints, described her as ‘tearful’ and ‘desperately’ requiring assistance. MCRT concluded that a DASH tisk assessment was required however this issi inimi vulnerable adult incident was actioned by the Contact 3 ~ 18" October 2012 Mrs Williamson contacted police reporting that her husband had assaulted her by pushing her to the ground, j j her back and riding her as if she was a horse. During this event PP ] hit his wife about the head. Officers. attended and witnessed in an agitated manic state. T ambulance was called checked Mrs Williamson and transported to gainst her husband (she signed an officer's pocket note book to that effect) and refused to be taken to hospital for a more thorough examination. MCRT concluded that force policy was followed in this incident with the completion of all requirements. Coroners ~ Matters of Concern woroners ~ Matters of Concern During the inquest the Coroner raised concerns that there was a risk future deaths will occur unless action was taken. The matters are detailed in section 5 of his letter. 1. A referral and assessment could have been made before or after April 2012, but most notably on or around 2™ — 4" April 2012 when the deceased GP made a direct referral to social services. This matter was not reported to Police. The first contact with the Williamson family was 8!" July 2012. Evidence was heard at the inquest suggesting that the GP was aware of domestic violence since December 2011, where bruising to Mrs Williamson was photographed at the surgery. 2. Had such an earlier assessment as a vulnerable adult been made then discussions would have taken place with all concerned with everyone having significant information sharing it with others. The earliest opportunity for Police to have made any referral to partner agencies was 8" July 2012; however this was not completed until the second interaction on 19" August 2012. 3. The DHR recommendations are endorsed. DHR — Recommendations and West Mercia Police Response Se tications and West Mercia Police Response The DHR did not make any specific recommendations for West Mercia Police. There are four ‘All Agency’ recommendations: Recommendation 1 - Risk Assessments All Agencies must review their assessment and management of risk for service users, their carers and significant others in their guidance for staff and provide an analysis of its effectiveness and how it is being monitored. Response: This recommendation does not appear to be wholly relevant to West Mercia Police. Risk Management Plans are used pro-actively to effectively manage risk, overseen by supervisors to ensure focus is maintained. Recommendation 6 — Domestic Violence All agencies must ensure that there are improvements in service responses for all domestic violence victims (both adults and children), all relevant staff to attend multi-agency training programme based on the DASH model. Response: This recommendation is not relevant to West Mercia Police as all operational staff are trained in the DASH risk assessment process. There are policies and procedures in place to guide staff and the DASH risk assessment process is utilised. This process is regularly audited by the Business Assurance Team with appropriate learning disseminated to staff. A reminder regarding the requirement to complete DASH, Crime Reports and Vulnerable Adult documentation will be provided to all operational staff. This will be completed by 31.01.14. Recommendation 7 — Support Services All agencies need to review their service responses to people who suffer from Alzheimer's and other Dementia Diseases and their Carers. This should be done in partnership with groups such as the Alzheimer’s Society who have significant knowledge and understanding of the issues. Response: MCRT commented that current training delivered to operational staff when dealing with vulnerable adults deals with mental health issues as a whole and does not individualise conditions such as Dementia and Alzheimer's. The recognition of a vulnerable adult by Police Officers and staff is considered sufficient to trigger a referral process for specialised assistance. The tactical equality and diversity advisor has recently attended a Dementia Friends workshop to scope the feasibility of additional awareness sessions. This is captured within the Warwickshire and West Mercia Mental Health Delivery Plan (action 18) with a completion date of 01.09.14 Recommendation 8 — Support Services A joint working group to be developed involving all agencies to address the increasing prevalence of dementia to identify the manifestation of harm to themselves or others and management plans to address these issues. Response: The arrangement of a joint working group will be tasked by the Safer Communities Partnership to the Safeguarding Adults Board. West Mercia Police will ensure full participation from specialist staff from the Protecting Vuinerable People Department. Details are currently awaited regarding the date of the first meeting. Conclusion The matters raised as a result of the DHR will be actioned as detailed above. This will be monitored until completion and discharged via the Strategic Oversight and Scrutiny Group, chaired by Assistant Chief Constable.
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