Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0150, written 3 Apr 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 3 Apr 2014 |
|---|---|
| Reference | 2014-0150 |
| Deceased | Danuta Corbett |
| Coroner | Veronica Hamilton-Deeley |
| Coroner area | Brighton & Hove |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
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.
VERONICA HAMILTON-DEELEY, LL.B. Her Majesty’s Senior Coroner for the City of Brighton & Hove Assistant Coroners CATHARINE PALMER LL.B (HONS) : 1s Telephone: Brighton (01273) 292046 MICHAEL KEEN Fax: Brighton (01273) 292047 KAREN HENDERSON, BSC,BM,MRCPLFRCA GILVA D.J.TISSHAW BA(LAW)HONS THE CORONER’S OFFICE WOODVALE, LEWES ROAD BRIGHTON BN2 3QB CORONERS SOCIETY OF ENGLAND AND WALES ANNEX A 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. Ms. Lisa Rodrigues, Chief Executive, Sussex Partnership NHS Foundation Trust 2. Head of Governance, Sussex Partnership NHS Foundation Trust 3. Legal Support Manager, Sussex Partnership NHS Foundation Trust 4 CORONER | am Veronica HAMILTON-DEELEY, Senior Coroner, for the City of Brighton and Hove 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 11" November 2013 | commenced an investigation into the death of Danuta Bronislawa CORBETT The investigation concluded at the end of the inquest on18th March 2014.The conclusion of the inquest was DANUTA CORBETT TOOK HER OWN LIFE WHILST DEEPLY DISTRESSED 4 CIRCUMSTANCES OF THE DEATH See Record of Inquest 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) The report concerns the leave policy so far as it relates to Informal Patients. (Copy enclosed — refer to S.4.5 and then S.43). (2) Leave was considered first on 1.11.2013 when Mrs. Corbett was on 15 minute observations. The Ward Review documents that she wants leave to go to her home to collect some papers over the next 2 — 3 days- Escorted leave agreed. No Leave occurred on 1™, 2™ or 3° November, 2013 but no reason for this is documented. On the 4" she has another Ward Review. She remained on 15 minute observations. As to leave, none of the matters referred to in the Policy at S.4.3 are documented in the Progress Note or in the Clinical Review or in the Electronic Note of the ward review on 4" November. In the afternoon of 4" November, Mrs. Corbett repeated her request to the Charge Nurse to go home. She was apparently Risk Assessed again and an escort was allocated. The escort was an agency health care worker who had never met the patient and had never worked on this ward before. No note by the risk assessment, or the decision to allow escorted leave was made in accordance with S.4.3 of the Policy. The patient's details and details of the reasons for her admission were not handed over to the escort, in particular neither the fact that her flat/home was central to her distress or the fact that she had threatened to kill herself by jumping from it were known to the escort. Thus none of the decisions regarding her Leave on the 4" November are documented. This patient jumped out of her 8" floor flat window at home during this escorted leave. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you AND 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 29" May 2014. I, Veronica Hamilton-Deeley 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. COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the following Interested Persons 1. 2. Secretary of State for Health, Department of Health 3. Sir David Nicholson/Simon Stevens — Chief Executive NHS England 4. National Patient Safety Agency | have also sent it to:- 1. Care Quality Commission 2. Agency Nurse Hanover Care 3. Director of Public Health 4. Director of Quality and Primary Care Who may find it useful or of interest. | 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. Date: 3” April 2014 SIGNED BY: a uf nar (Eu, Senior Coroner Brighton and Hove [6/1 Record of Inquest (: ae i & Following an investigation commenced on the | Eleventh a November 2013 The County Court, and an inquest heari William Street & The eae oe ng Magistrates Court, on the Fourteenth & Day of March 2014 a Edward Street, . Brighton Eighteenth Before and by (1)me Veronica HAMILTON-DEELEY Her Majesty’s Senior coroner for The City of Brighton & Hove and the under-mentioned jurors:- Florence Anderson, Mavis Ang, Hafiz Abdul Butt, Timothy Corner, Sean Dunford, Kenton Hadley, Samantha Ransom, Jackie Stock and Matt Wheeler The following is the record on the inquest (including the statutory determination and, where required , Findings) 1. Name of Deceased (if known) Danuta Bronislawa CORBETT 2. Medical cause of death la |HEAD INJURY b |FAL. FROom HEIGHT c = EPRESSION 1 |ARJUSTMENT DISORDE2 ASSOCIATED WUHAN XIETS, Ee a ent 3. How, when and where, the deceased came by his or her death SEE ATTACHED SHEET 4. Conclusion of the Jury as to the death DANUTA CORBETT TOOK HER OWN LIFE WHYST DEGOLY DisneeSSEX 5. Further particulars required by the Birth and Deaths Registration Act 1953 to be registered concerning the death (a) Date and place of birth Eighth October, 1954 Sopot, Poland (b) Name and Surname of deceased Danuta Bronislawa CORBETT (c) Sex (d) Maiden surname of woman who has married Female STAWOWY 4 (e) Date and place of death Fourth November, 2013 Roof of The Metropole Hotel, Kings Road, Brighton (f) Occupation and usual address Architect Widow of Barry Anthony CORBETT ---- 9a Metropole Court, Kings Road, Brighton Signature of HM Senior Coroner..¥......ff, AMAA Sin atts sabes tgies eectey Signatures of Jurors y tne * RECORD OF IN@UEST FCR DANUTA BRONISLAWA CORBETT 2. HON, WHEN 9 WHEeee, THE DECEASED CAME BY Hee D&ATH ON OA -I1- 20/2 AT THE METROPOLE COURT HOTEL, DANWUTA CORBETT A SIYR FENALE,WHO Han SUFFERED A SEVERE REACTION 70 THE DEAD OF HER HUSBAND AAID THIE RESUKTLAIG CONCERNS AROUND HER Home AND BNANCES TOOK HER OWN LIFE. AT THE TIME OF HER DEATH, DANWLTA WAS AN INFORMAL. PANENT IN) THE LOCKL NHS Run! HOSPLIAL ON! A PSYCH IRN WARD, NOP SUICLDAL IDEANINS 0F TUMPiNG FRon1 HER &T FLOOR AIR ARTUENT. SHE HAD REQUESTED HOME LEAVE FO RETLRN TO HER APARTMENT TO COLLECT SOME PERSOWAL. BELONGLNGS, THIS LEAVE WAS GRANTEQ BLT WAS NOT IN LINE Wei THE TRUSTS AECAVE POLICY. AT THE TIME OF Thee AEAVE DANMNUTA WAS DOCURIE WTI AS IN THE RED 2ONE| MEANMLNG SHE WAS AT HIGH RISK. SHE WAS ALSO OY ISMENUTE OCBSERVATIOWS. eh Mie | = f rey ® CORONERS & JUSTICE ACT 2009 Action to prevent other deaths Schedule 5 PARA 7(1) Where ---- (a) (b) (<) (2) (3) a senior coroner has been conducting an investigation under this Part into a person’s death, anything revealed by the investigation gives rise to a concern that circumstances creating a risk of other deaths will occur, or will continue to exist, in the future and in the coroner’s opinion, action should be taken to prevent the occurrence or continuation of such circumstances, or to eliminate or reduce the risk of death created by such circumstances, the coroner must report the matter to a person who the coroner believes may have power to take such action. A person to whom a senior coroner makes a report under this paragraph must give the senior coroner a written response to it. A copy of a report under this paragraph, and of the response to it, must be sent to the Chief Coroner. The Coroners (Investigations) Regulations 2013 PART 7 Action to prevent other deaths Report on action to prevent other deaths 28.—(1) This regulation applies where a coroner is under a duty under paragraph 7(1) of Schedule 5 to make a report to prevent other deaths. (2) In this regulation, a reference to “a report” means a report to prevent other deaths made by the coroner. (3) A report may not be made until the coroner has considered all the documents, evidence and information that in the opinion of the coroner are relevant to the investigation. (4) The coroner— (a) must send a copy of the report to the Chief Coroner and every interested person who in the coroner’s opinion should receive it; (b) must send a copy of the report to the appropriate Local Safeguarding Children Board (which has the same meaning as in regulation 24(3)) where the coroner believes the deceased was under the age of 18; and (c) may send a copy of the report to any other person who the coroner believes may find it useful or of interest. (5) On receipt of a report the Chief Coroner may— (a) publish a copy of the report, or a summary of it, in such manner as the Chief Coroner thinks fit; and (b) send a copy of the report to any person who the Chief Coroner believes may find it useful or of interest. Response to a report on action to prevent other deaths 29.—(1) This regulation applies where a person is under a duty to give a response to a report to prevent other deaths made in accordance with paragraph 7(1) of Schedule 5. (2) In this regulation, a reference to “a report” means a report to prevent other deaths made by the coroner. (3) The response to a report must contain— (a) details of any action that has been taken or which it is proposed will be taken by the person giving the response or any other person whether in response to the report or otherwise and set out a timetable of the action taken or proposed to be taken; or (b) an explanation as to why no action is proposed. (4) The response must be provided to the coroner who made the report within 56 days of the date on which the report is sent. (5) The coroner who made the report may extend the period referred to in paragraph (4) (even if an application for extension is made after the time for compliance has expired) (6) On receipt of a response to a report the coroner— (a) must send a copy of the response to the report to the Chief Coroner; (b) must send a copy to any interested persons who in the coroner’s opinion should receive it; and (c) may send a copy of the response to any other person who the coroner believes may find it useful or of interest. (7) On receipt of a copy under paragraph (6)(a) the Chief Coroner may— (a) publish a copy of the response, or a summary of it, in such manner as the Chief Coroner thinks fit; and (b) send a copy of the response to any person who the Chief Coroner believes may find it useful or of interest (other than a person who has been sent a copy of the response under paragraph (6)(b) or (c)). (8) A person giving a response to a report may make written representations to the coroner about— (a) the release of the response; or (b) the publication of the response. (9) Representations under paragraph (8) must be made to the coroner no later than the time when the response to the report to prevent other deaths is provided to the coroner under paragraph (4). (10) The coroner must pass any representations made under paragraph (8) to the Chief Coroner who may then consider those representations and decide whether there should be any restrictions on the release or publication of the response.
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.
A teaching trust of Brighton Sussex Partnershi p NHS| and Sussex Medical School NHS Foundation Trust Our Ref: INQ/13/118 Your Ref: VHD/LP/INQ16/14 9 June 2014 Arundel Road Worthing SEIVED D “ Swandean West Sussex Miss Veronica Hamilton-Deeley | : diet ioyicte ENISISEE HM Senior Coroner The Coroner’s Office Tel: Woodvale Lewes Road Brighton BN2 3QB Email: Dear Miss Hamilton-Deeley Re Danuta Corbett | am writing further to your report, written pursuant to the Coroners & Justice Act 2009 and the Coroner's (Investigations) Regulations 2013, regarding the Inquest in to the very sad death of Danuta Corbett. The concerns your report highlight relate to our policy for leave for non detained patients and, specifically, how staff managed the leave that had been agreed for Danuta from 1 November 2013, and how the plans made on 4 November 2013 were recorded. We acknowledge that despite having planned to support Danuta to return home over that weekend to collect some belongings, this did not happen. The primary reason was due to difficulty releasing a member of staff during what was an extremely busy weekend. Clinicians understand that leave can be an integral part of a person’s care plan and so when a patient needs to be supported by a member of staff then every effort is made to facilitate this. It is with much regret that the record keeping on Monday 4 November 2013 was so poor. Neither the detailed assessment carried out by the consultant during the ward review, nor the assessment completed by the nurse in charge shortly afterwards, were properly documented. This is a requirement of the leave policy, and a fundamental part of good clinical practice. The consultant psychiatrist has learnt a great deal from this experience. She now carefully reviews the notes taken during ward review, which are typically scribed by the junior doctor present. As you heard at the Inquest, the nurse did not make a note at all. This was because the incident happened shortly after her assessment and she was so distressed by what happened that she went home and did not return to work for several days. It is quite normal for nursing staff to write in patient notes toward the end of the shift. However, on her return the nurse ought to have written a clearly marked retrospective note. She did not do this after being advised at the time by the acting Matron that this was not appropriate. We have since reinforced with staff that should these quite extraordinary circumstances arise again then a retrospective note must be completed. Finally, it is clear that the communication with the agency nurse who was accompanying Danuta should have been much better. The nurse responsible acknowledges this and will always ensure proper handovers take place in the future. It seems unlikely that any of the shortcomings highlighted by this very sad case would have prevented the tragic outcome. However, all the staff involved in Danuta’s care have carefully reflected on what happened and used the learning to improve their practice. | hope this information is helpful and | confirm that we have no objections to it being shared or published by the Chief Coroner. Yours sincerely, Lisa Rodrigues CBE Chief Executive
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