Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0163, written 8 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 | 8 Apr 2014 |
|---|---|
| Reference | 2014-0163 |
| Deceased | Andrew Horgan |
| Coroner | David Ridley |
| Coroner area | Wiltshire & Swindon |
| 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.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Ms Nerissa Vaughan, Chief Executive, The Great Western Hospital, Marlborough Road, Swindon SN1 6BB CORONER | am David Ridley, Senior Coroner for the Coroner area of Wiltshire and Swindon 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. INVESTIGATION and INQUEST On 17 September 2013 | commenced an investigation into the death of Andrew Michael Horgan aged 46. The investigation concluded at the end of the Inquest on 08 April 2014. The conclusion of the Inquest was that Andrew had died from:- 1a) Acute cardiac failure 1b) Colchicine overdose 2) Coronary artery atherosclerosis, myocardial fibrosis, focal incomplete hepatic cirrhosis. | concluded that Andrew Horgan’s death was as a result of an accident — an unintended consequence of a deliberate act. CIRCUMSTANCES OF THE DEATH Andrew had recently split up with his girlfriend and was admitted to the Great Western Hospital in Swindon at 0018 on 14 September 2013 having over the previous 12 hour period consumed a variety of drugs including Colchicine with alcohol (other drugs included Clomethiazole and Dihydrocodeine). | found as a matter of fact that more likely than not Andrew himself called the ambulance from his flat at Flat 1 Daniel Gooch House, Rodbourne Road, Swindon. Following admission his condition was monitored, he was given intravenous fluids and whilst his Glasgow Coma Scale fluctuated the following day shortly after 1500 hours he that he self-discharge from hospital (GCS normal at this stage). [i spoke to him having appraised himself as regards the background to the case and was satisfied that Andrew had full mental capacity and understood the ramifications of his decision to leave hospital. He did not form the view that Andrew posed a risk of further self-harm, Andrew having indicated the reason for him wanting to leave was in respect of a meeting with his landlord. Following self-discharge Andrew was dropped off at his mother’s home and she walked him round to Andrew's flat and spent about an hour with him. They had further contact on Sunday 15 September 2013 and Andrew was last known to be alive at 1715 that evening. Andrew's body was discovered at approximately 1600 hours on Monday 16 September 2013 lying on the floor of his bedroom fully clothed at his flat. His death was confirmed by an attending paramedic at 1655 the same day. The examination after death revealed that Andrew had a compromised cardiovascular system reducing cardiac reserve as well as reduced hepatic reserve both of which contributed to his death as a result of acute cardiac failure which was attributable to the Colchicine overdose. The evidence that | had before me was that Colchicine remains in the body for some time and it can take a number of weeks to fully recover from an overdose. There is also no antidote as such to the drug. 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 duty to report these concerns to you. The MATTERS OF CONCERN are as follows. — 1, Training for Doctors and other medical staff in relation to referring patients for assessment both within the hospital and externally following discharge. — During the course of the Inquest —_ fae evidence and it was quite clear that he did not have a clear understanding of the referral procedure to involve professionals from the Avon and Wiltshire Mental Health Partnership. He believed his telephone conversation with the Swindon Intensive Services with CPN «oc result in the outreach team assessing Andrew in the community. He thought that a telephone call alone would be sufficient in that respect to engage the Mental Healthcare professionals. The importance of a clear and effective communication pathway following recognised and agreed practices and procedures cannot be ignored and | am concerned following the evidence | heard there were knowledge gaps as regards practice and procedures to be followed when engaging Mental Health Partnership personnel. | would be grateful if you could please review the appropriateness and the effectiveness of training in this respect not only for current GWH personnel but also how effective training in this area can be given to personnel in the future. Whilst | was satisfied that this did not contribute to Andrew’s death in this instance my concern is that an issue could arise in the future whereby that may not be the case. 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 03 June 2014. |, 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. COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the following Interested Persons:- Mr Simon Stevens, Chief Executive, NHS England, Mr lain Tulley, Chief Executive Avon and Wiltshire Mental Health Partnership NHS Trust. | am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both ina 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. StS 08 April 2014 HM Senior Coroner
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.
Great Western Hospitals INHS| NHS Foundation Trust The Great Western Hospital Marlborough Road Swindon SN3 6BB = Tel: 01793 60 40 20 8" May 2014 Private and confidential Mr David W G Ridley Senior Coroner for Wiltshire and Swindon Wiltshire and Swindon Coroner's Court 26 Endless Street Salisbury Wiltshire SP11DP Dear Mr Ridley Re: Regulation 28 Report to prevent future deaths Andrew Michael Horgan (deceased) Thank you for your letter of 10" April 2014 summarising the circumstances that led to the sad and untimely death of Mr Horgan. This letter sets out the Trust’s response to your report. Your letter raised concerns about this case, around the lack of understanding by medical staff about the procedure to engage our mental health provider, the Avon and Wiltshire Mental Health Partnership (AWP). Regulation 28 was issued because during the Inquest id not provide a clear understanding of the referral procedure needed to initiate an assessment by the community outreach team following Mr Horgan’s self- discharge from hospital. You requested that the Trust should review the appropriateness and effectiveness of training currently provided to all staff. The Deputy Chief Nurse who leads on compliance with the Mental Health Act for the Trust, has reviewed Mr Horgan's case with regards to the referral process and current training Our Values Service Teamwork Ambition provision. The review of the referral process and actions arising from this was carried out in collaboration with AWP. The findings, recommendations and actions are listed as follows: Referral to mental health services The review of the Trust’s referral process to mental health services showed that there is a clear referral process in place for patients in the Emergency Department or those admitted into Great Western Hospital (GWH). During 2013/14 staff referred 911 patients to the Adults of Working Age Psychiatry Liaison Service; 321 patients to the Adults of Later Years Psychiatry Service and 94 patients to the out of hours intensive team. In Mr Horgan’s case, there was a miscommunication as to whether the contact with the out of hours intensive team was for advice or referral to mental health community services upon Mr Horgan’s self discharge. The Trust and AWP both agreed that this area of practice should be made clearer to all staff. The AWP documentation record has now been updated to include a question making it clear that the telephone call from GWH staff is either for referral, advice or both. In addition, the Trust is advised that community crisis intervention as, in the case of Mr Horgan, is only accessible by the patient contacting the out of hours General Practitioners’ service. The patients’ General Practitioner will normally be informed about their admission or attendance to hospital through the Trust Patient Electronic Discharge Summary system. The Trust acknowledges that both staff and patients should be made aware of this and as a result, the information will be included in the patients’ information leaflet that will be available at the end of May 2014. In addition, this will be included in the Trust's Mental Health Act training programme and the Trust's intranet site will be updated to reflect this information. Review of Mental Health Act Training The Trust provides mandatory training to all clinical staff to support understanding of and application of the Mental Health Act (MHA), the Mental Capacity Act (MCA) and the Deprivation of Liberty Safeguards (DoLS). In September 2013, the Trust implemented face to face mandatory training as opposed to training via our E-Learning programme. The change was implemented because the Trust strongly acknowledges the value of face-to-face interactive learning, enabling staff to explore issues and learn from case presentation. A total of 82% of clinical staff had untaken Mental Health Act training and 94% MCA and DoLS during 2013/14. In addition to mandatory training, four one day sessions were held in the autumn of 2013 looking specifically at MCA and DoLS. A total of 91 clinical leaders from across the organisation attended the training that was delivered in collaboration with specialist leads for Wiltshire and Swindon local authorities, as well as the Trust's legal advisors, Bevan Brittan. Over the last two years the Trust has worked closely with AWP and commissioners to improve the delivery of an effective psychiatric service at GWH. The number of Mental Health Liaison nurses has increased from 2.6 wte nurses to 6.8 nurses, enabling bespoke Our Values Service Teamwork Ambition training to take place on wards and departments. In addition, the Trust now has a dedicated Consultant Physiatrist who was appointed by AWP and who commenced work with GWH on 4" May 2014. This new position will enable staff, in particular our medical teams, to have greater access to advice, support and training. The Trust is satisfied with the provision and impact of MHA training and also that this is monitored on a regular basis via the Trust’s internal governance arrangements. In conclusion, | hope that this response provides you with assurance that the MHA referral process to AWP and training provision at GWH are working effectively. However, the case has presented gaps in the recording of information by clinical staff and advice given to patients that may require support in the community following their discharge from hospital. Actions have already taken place to address the two issues. If you require any further information please do not hesitate to contact me. Yours sincerely Nerissa Vaughan Chief Executive Our Values Service Teamwork Ambition
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