Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0157, written 7 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 | 7 Apr 2014 |
|---|---|
| Reference | 2014-0157 |
| Deceased | Roger Duggan |
| Coroner | Elizabeth Earland |
| Coroner area | Exeter & Greater Devon |
| 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.
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. Chief Executive of the Royal Devon & Exeter Hospital NHS Trust Wonford 1 CORONER I am Dr Elizabeth Ann EARLAND, Senior Coroner, for the Exeter and Greater Devon 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. [HYPERLINKS] 3 INVESTIGATION and INQUEST On 15th February 2013 I commenced an investigation into the death of Roger Clive DUGGAN, Aged 61 years. The investigation concluded at the end of the Inquest on 5th March 2014. The conclusion of the inquest was Open Verdict: The Deceased was in a heightened anxiety state when he absconded from cubicle 8 in the Accident and Emergency Minors Department at the Royal Devon and Exeter (Wonford) Hospital at 00.47 hours 11th February 2013, after which, at some point, he entered the River Exe opposite Mill Lane. He also had ischaemic heart disease. 4 CIRCUMSTANCES OF THE DEATH 10/2/13 Wife had given him 2 x Diazepam approximately 2100-2130hrs and kept the packets in her handbag. He was in a very agitated state, pacing. Wife rang the crisis team who suggested they call 999, he said to his Wife "he wanted to get out and would not be back". After some considerable delay the Ambulance arrived and he was taken to A&E Minors RDE via ambulance late that night, but absconded from the department via main entrance at 0047hrs 11/2/13 and is shown on CCTV to leave the site shortly afterwards. An extensive search was carried out by Police in the area with no sightings. 12/2/13 Mr Duggan's body was located by a group of canoers in the water at a tributory to the River Exe, opposite Mill Lane Exeter, his body was recovered by joint emergency services and confirmed deceased at 1430hrs. Police happy no suspicious circumstances. Deceased's glasses were found, intact in his pocket. Wife states he always wore them and believes he took them off purposefully. 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. 1 The MATTERS OF CONCERN are as follows. – [BRIEF SUMMARY OF MATTERS OF CONCERN] (2) Mr Duggan was brought to the Emergency Department of the Royal Devon & Exeter Hospital (Wonford) late on the evening of the 10th February 2013 in a state of heightened anxiety and agitation. Night Senior Nurse Mental Health Practitioner, assess. I received Evidence that in Minors area (which was supervised) asking the staff nurse to sit with Mr Duggan while he spoke with the family. He was told that they would keep an eye on Mr Duggan. was called to left the Deceased in cubicle 8 No one saw Mr Duggan leave the cubicle until the CCTV picked up his exit from the unit at 00.47 hours on 11th February 2013. It appears from Evidence that neither the Senior Nurse Mental Health Practitioner not night staff on the unit took responsibility for watching Mr Duggan. Mr Duggan was found Deceased in the River Exe at 14.30 hours 12th February 2013. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent further absconsions of vulnerable psychiatric patients from the hospital. This would appear to involve a clear delineation of where responsibility for the observation of these patients in the Minor area vis à vis the regular night staff and Visiting Mental Health Practitioners called to assess the patients in psychiatric emergencies. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 2nd June 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 I have sent a copy of my report to the Chief Coroner and to the following Interested Persons. General Practitioner, the Deceased’s next of kin. I have also sent it to Mr Duggan’s 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. 2 9 Inquest Date: 5th March 2014. Date of Report: 7th April 2014. ……………………………………………………….. Dr Elizabeth A Earland MB.Ch.B.,D.A.,Dip.Law,L.P.C,Hon.LLD HM Senior Coroner 3
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. South West Ambulance Service 1 CORONER I am Dr Elizabeth Ann EARLAND, Senior Coroner, for the Exeter and Greater Devon 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. [HYPERLINKS] 3 INVESTIGATION and INQUEST On 15th February 2013 I commenced an investigation into the death of Roger Clive DUGGAN, Aged 61 years. The investigation concluded at the end of the Inquest on 5th March 2014. The conclusion of the inquest was Open Verdict: The Deceased was in a heightened anxiety state when he absconded from cubicle 8 in the Accident and Emergency Minors Department at the Royal Devon and Exeter (Wonford) Hospital at 00.47 hours 11th February 2013, after which, at some point, he entered the River Exe opposite Mill Lane. He also had ischaemic heart disease. 4 CIRCUMSTANCES OF THE DEATH 10/2/13 Wife had given him 2 x Diazepam approximately 2100-2130hrs and kept the packets in her handbag. He was in a very agitated state, pacing. Wife rang the crisis team who suggested they call 999, he said to his Wife "he wanted to get out and would not be back". After some considerable delay the Ambulance arrived and he was taken to A&E Minors RDE via ambulance late that night, but absconded from the department via main entrance at 0047hrs 11/2/13 and is shown on CCTV to leave the site shortly afterwards. An extensive search was carried out by Police in the area with no sightings. 12/2/13 Mr Duggan's body was located by a group of canoers in the water at a tributory to the River Exe, opposite Mill Lane Exeter, his body was recovered by joint emergency services and confirmed deceased at 1430hrs. Police happy no suspicious circumstances. Deceased's glasses were found, intact in his pocket. Wife states he always wore them and believes he took them off purposefully. 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. 1 The MATTERS OF CONCERN are as follows. – [BRIEF SUMMARY OF MATTERS OF CONCERN] (1) Whilst it was apparent in evidence that matters had reached fever pitch at Mr Duggan’s home, The Lindhay, The Old Farmhouse, Brampford Speke, on the evening of the 10th February 2013 as he reached a severe anxiety state. The family were firmly of the view the initial calls to Ambulance Control were not treated sufficiently seriously (despite the family being advised to do so by the Crisis Team). An ambulance visit only materialized after a further call to the Crisis Team and the latter’s instruction to Ambulance Control to attend. It appears that staff lacked the necessary training to deal with Mental Health Crisis. After subsequent arrival at the Royal Devon and Exeter Hospital (Wonford), Accident and Emergency Department, later that night 10th February 2013 Mr Duggan absconded only to be found deceased in the River Exe at 14.30 hours 12th February 2013. 6 ACTION SHOULD BE TAKEN In my opinion there is a case for examination of the staff response to s calls on 10th February 2013 and an assessment of whether further training in the evaluation of psychiatric emergencies is required. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 2nd June 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 I have sent a copy of my report to the Chief Coroner and to the following Interested Persons. General Practitioner, the Deceased’s next of kin. I have also sent it to Mr Duggan’s 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 Inquest Date: 5th March 2014. Date of Report: 7th April 2014. ……………………………………………………….. Dr Elizabeth A Earland MB.Ch.B.,D.A.,Dip.Law,L.P.C,Hon.LLD HM Senior Coroner 2
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.
South Western Ambulance Service [a' NHS Foundation Trust RECEIVEL 2 SWAY ie 27 May 2014 Trust Headquarters Abbey Court Eagle Way Your reference: EA3/DMT File No: 404/20 Exeter EX2 7HY Dr Elizabeth A Earland Aheatrrceetirr4 HM Senior Coroner for the County of Devon Website: www.swast.nhs.uk Exeter and Greater Devon Coroner's Office Room 226 Devon County Hall Topsham Road EXETER EX2 4QD Private and Confidential Dear Dr Earland, Roger Clive DUGGAN Deceased — Inquest: 5 March 2014 at County Hall, Topsham Road, Exeter Coroner’s Rule 28 Report Thank you for your letter regarding the above inquest under Paragraph 7 of Schedule 15 to the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. Please find the Trust's response below: Recommended Action Yi egulation 28 Report states that there is a case for examination of the staff response to calls on 10 February 2013 and an assessment of whether further training in the evaluation of psychiatric emergencies is required. Response Following notification of the incident by Northern, Eastern and Western (NEW) Devon Clinical Commissioning — = the Trust conducted an investigation into the ambulance response to calls. This investigation was completed in May 2013 and forwarded to NEW Devon CCG for inclusion within the Serious Incident investigation which they led on. A meeting chaired by NEW Devon CCG, and attended by all agencies involved, subsequently took place to discuss the findings of the investigation and develop an action plan. A copy of the investigation report is appended to this letter, unfortunately this Trust was not aware that the inquest into Mr Duggan’s death was taking place as we would have been able to provide you with a copy of that report and details of other actions that have taken place since the incident which would have addressed the concerns raised in the Regulation 28 report. The investigation concluded that there appeared to be a misunderstanding by the Crisis team on the correct procedure for requesting ambulance transport for patients who required assessment or have a pre-arranged admission which subsequently led to communication difficulties. Following the meeting chaired by NEW Devon CCG, information was disseminated regarding the correct process for arranging transport and would have resulted in an appropriate ambulance response. In order to provide some context into ‘ “ “ou Emergency Medical Advisor (EMA) who received the telephone calls from | would like to explain the triaging system that the Trust’s Clinical Hub uses to categorise incoming calls. The triage system used by the Trust is called ‘NHS Pathways’ and all 999 calls to the Trust are triaged using this system. When a call is received by the Clinical Hub the caller is questioned and the outcome of those questions determines the classification according to the patient’s clinical need. This is to ensure that emergency medical help is sent to life-threatening incidents without delay. The system aims to have a clinically robust and consistent, yet compassionate and understanding, approach to telephone triage and it is designed to effectively identify the level of care needed. The system is also able to signpost callers to more appropriate care pathways and therefore more tailored to the caller's requirements. An alternative pathway includes a wide range of healthcare alternatives that is considered a more appropriate option than conveying a patient directly to Accident and Emergency Departments by ambulance. There are a broad range of professional health care providers who are accessible to members of the public to treat and advise patients, for example GPs, out of hours providers, minor injury units, treatment centres and pharmacies. The Trust’s investigation identified that not all the appropriate ‘NHS Pathways’ questions were asked by the EMA and that they should have sought further advice from a Clinical Supervisor within the Clinical Hub. As part of the investigation the EMA completed a reflective practice on their involvement in this case. Following this incident, in July 2013, the Trust upgraded its version of ‘NHS Pathways’ to version 6.5.1 which included a dedicated Mental Health Pathway. This was developed in consultation with specialist Mental Health Teams and allows for patients with mental health symptoms to be dealt with more efficiently with the outcome of the triage (the disposition) being more appropriate. Prior to the implementation of version 6.5.1 all existing Clinical Hub staff were trained in the use of the Mental Health Pathway, this training is also provided for ail new Clinical Hub staff as part of their ‘NHS Pathways’ training and includes scenarios. In order to monitor the Trust's response to patients with Mental Health concerns and develop robust policies, procedures and guidelines to improve the quality of care provided, a Mental Health Group has recently been established. This Group is chaired by a Trust Clinical Development Manager and is attended by managers from key areas of the Trust, including the Clinical Hub. A copy of the draft terms of reference is attached for your information. . | hope the information contained within this letter provides you with assurance that steps have been taken by the Trust, in liaison with the local health community, to learn from this tragic event. If you require any further information, please do not hesitate to contact me. Yours sincerely, Ken Wenman Chief Executive Enc: SWASFT Serious Incident Report Mental Health Group, Draft Terms of Reference —_~ at May, tty SYS ze SEE (he Crompl Payment Code VMS ‘airman: Heather Strawbridge 5 — E a iief Executive: Ken Wenman Sign up https#secure.membra.co.uk/swambapplicationfonn/ to be & membe
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