Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0067, written 19 Feb 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 19 Feb 2014 |
|---|---|
| Reference | 2014-0067 |
| Deceased | Simon McAndrew |
| Coroner | Dr R N Palmer |
| Coroner area | London (North) |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Central and North West London NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
H.M. Senior Coroner, South London Area
South London Coroner's Office
Saint Blaise Building, Bromley Civic Centre
Stockwell Close, Bromley BR1 3HU
Telephone 020-8313 1883 Fax 020-8313 3673
Coroners & Justice Act 2009; Coroners (Investigation) Regulations 2013
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1)
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
Chief Executive of Central and North West London NHS Foundation Trust
Trust Headquarters, Stephenson House, 75 Hampstead Road, London NW1 2PL
1
CORONER
I, Dr Roy Newberry Palmer, am senior coroner for the South London coroner area.
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, SI 2013
no. 1629
3
INVESTIGATION and INQUEST
On 3rd July 2011 I opened an inquest into the death of Simon William McAndrew, aged
38 years. The inquest was concluded on 13th February 2014.
The cause of his death was
1a hypoxic ischaemic encephalopathy
1b fatal pressure to the neck/suspension
I recorded a narrative verdict on this matter, as follows:
Simon McAndrew had a long history of emotionally unstable personality disorder,
substance abuse and self harm. He was a voluntary inpatient of the Gordon Hospital for
several months in 2010.On his discharge arrangements were made for him to be
resident at Jordan Lodge in Croydon but his ongoing psychiatric care was supervised at
the Gordon Hospital. He harmed himself in April 2011 and attended Croydon Hospital
where he was assessed by the emergency department and by a psychiatric liaison
nurse. His methadone prescriptions were managed at Lantern Hall, Croydon. On 28th
June 2011 at Jordan Lodge he was seen holding some belts. Fearing for his safety staff
at Jordan Lodge removed the belts and monitored him closely for some time. He
appeared to settle down. They did not seek advice. At about 01.00h Simon McAndrew
was found hanging from a tree in the garden at Jordan Lodge. Staff cut him down and
initiated cardiopulmonary resuscitation. Police and ambulance personnel were called,
assisted in resuscitation and transferred Simon to Croydon Hospital where he was taken
to the intensive care department and neuroprotective strategies were implemented. His
condition deteriorated on 30th June 2011 and he was found to have suffered an
extensive subarachnoid haemorrhage. Brain stem testing was performed on 3rd July
2011. Death was confirmed at 11.45h. He died as a consequence of an act of self harm.
Issues of poor communication and confusion about who was responsible for his
1
psychiatric care were probably not contributory to his death but do warrant a Prevention
of Future Deaths Report
4
CIRCUMSTANCES OF THE DEATH
See box 3 above;
Simon McAndrew died on 3 July 2011 at Croydon University Hospital, London Road,
Croydon, Surrey. He was a voluntary residential patient at Jordon Lodge, Croydon, at
the time of his death.
He had suffered brain damage as a child and childhood epilepsy. Into adulthood, he
experienced drug abuse issues and was diagnosed with Emotional Personality Disorder,
a chronic mental health condition. On 30th June 2011 Mr McAndrew was seen by staff of
the home where he resided to be making nooses from belts. They were confiscated, and
he was placed on a one-to-one watch. This was relaxed later in the evening when he
appeared to have clamed down. He later used a plastic washing line to hang himself
from a tree in the garden of the home, having told staff he was going outside for a
cigarette. He was discovered and two staff members attended the scene, performing
emergency First Aid. An ambulance was called and Mr McAndrews was taken to
hospital, where he died on 3rd July 2011.
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.
Representatives of your Trust attended the Inquest and many brief you more fully. In
summary the MATTERS OF CONCERN are as follows.
There are issues of poor communication which need to be addressed. I acknowledge
that even the most detailed communication in this instance may not have averted Mr
McAndrews' actions and subsequent death. However, circumstances in which important
information is not being shared effectively may result in avoidable tragedies in future if
remedial action is not taken.
I invite the Trust to consider whether improvements can be made, particularly with
regards the sharing of information between different NHS Trusts. In the comments that
follow I do not intend to be prescriptive or to make firm recommendations; rather I seek
to encourage you to consider the issues that arose and what might be done to try to
prevent any recurrence.
Mr McAndrew had a drug misuse issue and a mental health issue. Each was dealt with
by different specialist psychiatrists. After a long period of in-patient treatment at the
Gordon Hospital Mr McAndrew was located in a residential home in another Borough.
His key caseworker was not easily able to keep in touch with him. His methadone
management was managed by Lantern House, a local NHS facility in the London
Borough of Croydon. When acute psychiatric issues arose Lantern House staff ordinarily
worked in close liaison with the local acute mental health trust (SLAM). At the material
time it was not appreciated that Mr McAndrew’s psychiatric care remained with the
Gordon Hospital.
Correspondence from one trust to another was copied to the consultant psychiatrist at
Lantern Hall but was not seen by her. This might have been because she was on leave
when it was received and the copy letter was then scanned into the electronic patient
record but not left in the consultant’s ‘in-tray’ for perusal on her return. An opportunity
was missed to ensure effective communication with the Gordon Hospital staff. Junior
staff, whether medical or nursing, had no ‘front page’ on the electronic patient record
that contained information that the primary psychiatric care was held by the Gordon
Hospital; so an inappropriate referral was made to SLAM.
2
For so long as the national computer database for all NHS patients is a far-off ideal,
some better method must surely be devised to ensure that key clinical staff can access
important information held electronically in a different NHS Trust. This is especially
important in psychiatric illness, where patients may not be able to provide the relevant,
important information themselves.
One possibility raised during the inquest hearing - which might go some way in
addressing this issue - is for patients to carry a "Crisis Card", containing details of the
Consultant and Hospital responsible for the main psychiatric care. Whilst it is conceded
that such cards cannot be compulsory, nor will they always be carried, the provision of
such cards for voluntary uptake might be worthy of consideration. Those called upon to
deal with crises in management would then more easily be able to ascertain important
information to help with management.
The Trust may also like to consider the unintended consequences of the use of different
computer databases in Trusts and how they might better be managed. Even within
individual computer systems, the evidence heard in this case suggests that the
information may be available but often staff - particularly junior staff - do not know to look
for it, may not know where to look for it and might not have the time to delve deep into
the electronic record to find it. If a "front of file" note could be created in each case to
record basic, essential information this may assist medical staff in discerning the
appropriate mental health professional with overall care in any particular case. Of
course, such information must be accurate and up-to-date.
I believe it was accepted by all who so helpfully attended to give evidence at the inquest
that there were too many miscommunications in this case and that steps should be
taken to try to ensure an improvement.
An additional point is that where discharged in-patients are resident in homes far distant
from the ‘base hospital’ and their key caseworkers, a better means must be devised of
keeping in touch with the patient. In this case the key caseworker conceded that she did
not keep in touch with Simon as much as would have been the case had he remained
resident locally. At best regular contact would have been by telephone rather than face-
to-face, albeit that occasional face-to-face contact was being arranged.
Please will you also consider whether a formal, written care plan should be provided to
the distant residential home with clear guidance as to what is to happen in defined
circumstances of crisis. If the staff at Jordan Lodge had had the benefit of a care plan,
they might have contacted the acute psychiatric team on 30th June 2011 to seek advice
as how best to manage the immediate crisis. In the absence of a care plan, and with
residential home staff who are not mental health professionals, the staff who were on
duty on the day were left to deal with the crisis as best they could. Is that state of affairs
capable of improvement?
6
ACTION SHOULD BE TAKEN
Although the death was to some extent impulsive and unpredictable, in my opinion a
number of issues of concern arose in the course of the evidence that lead me to
consider that action should be taken to prevent future deaths. I believe you have the
power to facilitate appropriate action being taken with a view to improving
communication between institutions and individuals and to arrange for staff who are
called upon to deal with crises have immediately available to them in easily accessible
form a summary of the main physical and mental health issues and details of the teams
that are responsible for relevant aspects of patients’ care.
7
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report,
namely by April 19th 2014. I, the coroner, may extend the period upon request.
Your response should contain details of action taken or proposed to be taken, setting
out the timetable for action, or should explain why no action is proposed.
8
COPIES and PUBLICATION
3
I have sent a copy of my report to the Chief Coroner and to the following persons
Chief Executive of South London and Maudlsey NHS Foundation Trust
Addictions Clinical Academic Group (CAG)
Lantern Hall, 190 Church Road, Croydon, CR0 1SE
General Practitioner;
Violet Lane Medical Practice, 231 Violet Lane, Croydon, CR0 4HN
The Manager, Jordan Lodge Residential Home
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
Dr R N Palmer
Senior Coroner, South London Area
19th February 2014
4
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