Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0009, written 6 Jan 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 6 Jan 2014 |
|---|---|
| Reference | 2014-0009 |
| Deceased | Daniel Williams |
| Coroner | Nicola Mundy |
| Coroner area | South Yorkshire (East) |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| 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: REPORT TO PREVENT FUTURE DEATHS
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
1. The Chief Executive of Rotherham Doncaster and South Humberside NHS
Foundation Trust
2. The Executive Medical Director of Rotherham Doncaster and South
Humberside NHS Foundation Trust
1
CORONER
I am Nicola J Mundy, Senior Coroner, for the Coroner area of SOUTH YORKSHIRE,
EAST DISTRICT.
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 21st June 2013 I commenced an investigation into the death of DANIEL WILLIAMS,
AGE 24. The investigation concluded at the end of the inquest on 2ND JANUARY 2014. I
concluded that the cause of death was 1a HANGING and returned a NARRATIVE
CONCLUSION as follows:
In May 2013 Daniel Williams was admitted to St Catherine’s Hospital following an
episode of deliberate self harm by way of insulin overdose. This was on a background
of psychiatric problems which developed following a diagnosis of diabetes which had
profoundly effected him.
During the course of his admission superficial enquiries by staff and unreliable record
keeping compromised the quality and completeness of the clinical information which in
turn compromised the effectiveness of the risk assessments. Poor communication
exacerbated matters. All these factors served to further increase Mr Williams’ significant
risk of self harm.
On 15 June 2013 Daniel Williams died from hanging following self application of a
ligature in his room at St Catherine’s Hospital.
4
CIRCUMSTANCES OF THE DEATH
Daniel Williams had been diagnosed as suffering from Diabetes as the age of 19. This
profoundly affected his mental wellbeing and also had physical implications too. As a
consequence he engaged with the psychiatric services and his final admission to
hospital was on the 23rd May 2013 following an overdose of insulin. Mr Williams
suffered from suicidal thoughts for much of that admission and appeared to be
considering alternative methods for ending his life. There were a number of risk
assessments and one to one meetings, many of which appeared not to explore in any
depth his suicidal thoughts and intent. On the 15th June 2013 Mr Williams hanged
himself with a bedsheet by knotting one end and securing it in the door jamb to the en
suite bathroom and tying the other end tightly around his neck.
1
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) Quality of staff training, particularly with regard to record keeping and
communication.
(2) The emphasis on taking a holistic approach to care and whether there is an
imbalance between adopting such an approach and patient safety.
(3) The absence of clear guidance for checking patients and their rooms for potential
self harm items both in the rooms themselves and for items brought into the
hospital.
(4) The absence of a single reference sheet in the notes summarising key issues, risk
factors, significant incidents and concerns readily accessible to all involved in
patient care.
6
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe you and
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 Friday 28th February 2014. I, the Senior 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
I have sent a copy of my report to the Chief Coroner and to the following Interested
of Henshaw Pratt Solicitors, the mother of the deceased
Persons:
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.
9
6 January 2014 Senior Coroner, South Yorkshire (East)
District
2
3
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.
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