Prevention of Future Deaths reports · 2014

Ozan Atasoy

Regulation 28 report to prevent future deaths, reference 2014-0166, written 9 Apr 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report9 Apr 2014
Reference2014-0166
DeceasedOzan Atasoy
CoronerEdward Thomas
Coroner areaHertfordshire
CategoryHospital Death (Clinical Procedures and medical management) related deaths
Sourcejudiciary.uk record · original PDF
Responses published1

The report

Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.

CORONER'S OFFICE
DISTRICT  OF HERTFORDSHIRE

The  Old Courthouse, St Albans Road  East' Hatfield,  Hertfordshire,  AL10  oES
DX: 100702  Hatfield
Tel: 01707 292780 Fax  01707  897399

MRGRAHAMoon"u*',Blr'#lt?o.hllL?ittBlf  li3.fi,"3lilr,ro*o^oroLoMoNs
Assisiant Coroners

I April  2014

Sent by email  to

The  Compliance  Manager
Care Quality  Commission
Citygate
Gallowgate
Newcastle  upon Tyne
NE1 4PA

Your  Ref: to be advised
Our Ref: 01254-2012

Dear Sir,

Re: Ozan Cem  ATASOY,  deceased
I am writing  to you under  the  provisions  of schedule  5 (paragraph 7) of the coroners & Justice
Act 2009 which came into force in July 2013. This re-enacted  the  provisions  of the old  Rule  43
of the Coroners Rules 1984. Attached  to this  letter  is information  concerning the new rules and
regulations from which  you  will see requires a written response.  Copies  oi this letter and the
response received  from you will be forwarded to the other interested  persons  identified at the
Inquest  In accordance  with the list attached.  I am also sending a copy of this letter  to the
Department  of Health  for their general information.

on the  28th February 2014,  l. concluded an inquest  that  I had conducted  over four days  with a
l_ur{ into the tragic death of ozan cem  Atasoy  (whom lwill  hereafter rere.to a, oz"ni.'pt""r"
find attached  a copy of the  Record  of Inquest,  which includes  the jury,s findings. ozan  suffered
from treatment  resistant  schizophrenia  following  diagnosis  in tg9g. ozan wis predominan  y
under  the care of 
 with  whom thl family  indicated  they hai a looo ano
trusting relationship.  Ozan had a.number of in-patient  admissions  which when  in Herfrordshire,
 ilso continued  as
his 
.community  clinician  supporting  him, with a care coordinator,  in trying io maintain  staoitity
while resident  in his ftat in Hatfietd. 
Qz.an  l.rgo been prescribed  nign'do"ses  or Joiapine,  orr
there was a deterioration  in his mental health, particuiarly recenfly  irhilst taking  tne iJgar  nign
'Natural waves". His family  reported  that ozan's reason for taking  .Natural  vi"u"i;,i". tn"t
they were  legal and also helped him deal with the auditory corn'mand  hallucinations  which
commanded  him  to take risks that severely jeopardised his saiety.

would  remain  his responsible clinician. 

Cont'd.  .. ..  .

 Page Two

Ozan Atasoy

In April 2012, Ozan's condition deteriorated to the extent that  he was  admitted voluntary  to the
Mymms ward at the Queen Elizabeth  ll Hospital, welwyn  Garden city, and then after
absconding several  times,  detained  under section 3, overwhelmingly  for his own safety
according  to 
. After further absconding he was placed in the local  psychiatrii
Intensive care Unit for approximately  seven days. (please  see attached  chronology  that was
agreed to by the interested persons) You will note the number of times that  Ozan lbsconded,
believed always from the smoking  area and  often when  escorted  on breaks  bv nursino staff.
on the last time he absconded  on the 6th  May 2e12, it appeared  he "tail  gated"  an informal
patient  who was  allowed to leave without being  escorted.  The doors on the iloor to the  lift had
been  opened  when a release button in the  nurses'  room  had  been  activated. The  geography  of
the unit meant  that the health care assistant  did not have a full view of the door when  sne
pressed  the button to release  those  doors.

ozan's body  was found some 13 days later  and from toxicology  analysis  it appears  he died
within  24 to 68 hours form  the time that he last  took  his Clozapine  at breiKast time on 6th May.

Mymms  ward  is situated at Queen  Elizabeth ll Hospital,  welwyn  Garden  city, which  is also a
general hospital. Mymms  ward is one of three wards in the psychiatric  unit and is on the
second  floor accessed  by lifts- The building  was erected in the 1960's  and  was originally  run oy
the general hospital. until  2009 there was a smoking  room which  patients 
use. N"*
regulations concerning  smoking  in enclosed  premises  and the need to access fresh  air meant
the garden was the only place  where patients  could  smoke  whilst  in the confines of the unit. A
1.74  mette  fence  was erected and Ozan  was able to vault  that  height in order to leave  the unit.
Mymms  ward and the other tw9.wlds  in the psychiatric unit  arJdesignated  an open wards,
and the jury and I were informed  that  there  are noiegulations  in respect-of  the heighi  of fencing
that provided  an enclosed area  for fresh air and smoking.  After Ozan's death in 20"1i the height
of the fence  was increased  to 3 metres,  which I was told- was the height required  for low secure
services,  and even  then there has been one  incident  of abscondirig  uy inottrei  paiient. rne
Trust operating  the unit is most reluctant  to.cage,,the area, no doub-t  to avoid patienis reeting
they  are in a "prison"  environment.  Incidentafly, ihe unit manager informed me tney n"u", n"u"
children  as in-patients in this unit.

"or]d 

The  Acute  service Manager gave  evid€nce 
thal  they  needed  to have obtained the permission
of the Acute  Trust  at the general hospital  and  planning permission  to increase  the height  of the
fence. Despite  contact  with the-  local.authority  on two  6ccasions  for advice after Ozan 
oi"o,
there had been  no response 
that authority  but they raised  the rence  ln *v 
rh"
Trust  has now confirmed that there  were plans  for all units  in Hertfordshire  simiraiiolire unit at
Welwyn  Garden  City to be closed,  A purpose built unit is in the course of construction  aitne  oto
Harperbury  Hospital  site which will shorfly  be opened.

"u"nt. 

.from 

-n"o 

There were other issues  raised at the inquest,  which  arthough  courd not be said to have
contributed  to ozan's  death, were nonetheless  matters  I felt ilould oe rreiprur to 
you,
your role as protecting and monitoring  services at mental healih  in-patient  units.
3ttenti9n.t9.l.n 
lwas told that there are many psychiatric  units  in acute trusts built in a similar way  ano
therefore  some  of the changes  beingmade might  be usefur  for units throughout  the country.
The  primary  structural  changes  apart  from moving site  are:

'ir.* 

.  The  raising  of the fence  from  1.74 metres to about  3 metres.
o  The.security of the door reading  into the garden  can  onry  be opened by staff by swipe

card,  given  that  the previous  door  was eisy  to open  by pushing hafd. 

'

Cont'd

 Page  Three

Ozan  Atasoy

.  The release  buttons  for  doors  to the  unit should  be operated by somebody  wno was
aOfe to nave tuff  anO uninterrupted  access to the  sight of the  doors so  they  could  see
wno  was going in  anO out and whether  somebody  would be "tail gating"-

now  records who  was  at external  doors betore  opening  systems  are

.  ih" ccri 

"vit", 
operated  remotely

The  iurv's  findinqs included  a failure  to communicate  concerns  about the height  ol the fence  to
r"niii i,"n"g";"nt 

a general lack of communrcation  with  management

"nd 

Observations
AiG i;;  oi ozan's  death his  observations  had  been  changed  from 15 minutes to every 5
rinuLs.  ntte, the  attempted  tail{aiting incident  of the  3'd  May 2012' the.jury felt that  the
oUa"ritlona  should have been  inCreasid  to contlnuous in accordance with the treatment and
care  ptin.  gvidence  was  given that  although staff had  been-given  in-house  training  the care
assisiant could  not recoll;ct  having  received  any  training. Training  is now  provided by an
externaltrainer  which staff  have found  helpful

The  observation  policy has changed  so  that  there  are  no "5  minute  observations".

The iury concluded failure to change  the observations  to continuous  after  the attempted tail-
gaitrng  Incrdent  on the 3a May significantly  contributed  to Ozan's death. A I to 2 majority
concluded  that any  return  to PICU  was unnecessary  as evidence  from PICU  was that they
would only be able to have Ozan  for no more than two months and  many  of the patients  were
violent  and sometimes  required 3 to 1 containment.  Ozan never  posed  any management
problems  whilst  on the  ward  beyond  staff  being extremely  alert  to the possibility  ol absconding.

Named Nurse
Ozan  was  allocated  a named nurse. He had a care  coordinator  in the  community  and  the
Serious  Incident  Report indicated  the named  nurse  was unclear  that they were the named
nurse or their  role.  I understand further  training  has been on the role  of a named  nurse since
the  incident

Occupational  Therapy
There  was  discussion  at the inquest on the provision  of occupational  therapy and the note
indicated  that  there was  occupational therapy although not at weekends,  as well as refenal  to
psychology  and to substance misuse  specialist  support.  The treatment plan was  lor Ozan,s
mental  health  to be stabilised  once  the effect of,Natural  Waves"  on his mental  health  had
diminished.  Ozan  presented  as  quiet  and was  difficult  to communicate  with, no doubt  due to the
impact  of his  voices.  The family  felt there  was a lack of engagement  with Ozan  on the  ward.

Staffing  Levels
Mymms  Ward  was able  to accommodate  twenty patients.  At  the  time of the incident  there  were
fifteen  on the  ward  with  two on teave.  Nine  of those patients  were  detained, eight  under Section
3 and one  under Section  37141  . lnformation communicated during  handover'was  good;  tt was
recorded in bold type that Ozan  was  "very high risk of absconding.  No  breaks offlhe ward at
present".  Each  patient  had details about their status, leave  entiflement and  risk. which  was  also
communicated  on a whiteboard in the office. The  normal staffing ratio  for this number  of
patients was two nurses  and three  health care assistants.  The stafiing ratio at plCU was five
staff to ten  patients.

Cont'd

 t.....

Page  Four

Ozan Atasoy

  gave evidence  of the changes  to those likely to be admitted  to a hospital  over
the years that  he had been in practice and iiis clear  that  many of those who  might have  been
admitted in the past, usually informally, are now  cared  for in thl community by thL crisis  teams
and with the early  intervention  psychosis  team. This therefore means  that patients  who are
admitted are likely t9 be more  complex  regarding  risks and the hando
  indicated  that
t?ny of those  patients  certainly  had risks retating to self harm. 
gave
evidence  that many of the experienced staff  with  whom he had  worked over a number  of yiars
had moved  to working  in community  teams, which  he felt had affected the calibre of staff
working on the ward and the way the staff  engaged  with patients.

I was given  copies  of the following documents:

Right Time

'  "How to Ensure  the Right  People,  with the Right Skills,  are in the Right  place at the
'  A Guide to Nursing,  Midwifery  and Care  Staffing  Capacity  and Capability
r  Forward  from the chief Nursing  officer for England,  Nurje cummlngs,'.

I noted  on page 25, case study  number  three from the Hertfordshire  partnership University
Trust concerning  the updating of "Managed  Exit and Entry  Policy",  focusing on correct  and safe
staffing  on acute admission  wards when informal  patients  are entitled to leave  the unit and
formal patients  detained under the Mental  Health Aci.

I have drawn your attention to the number of issues raised at the inquest and to the changes
Hertfordshire Partnership  University Trust have put in place in order for them  to try and lelrn
the lessons  from the tragic death of Ozan.  I wouid be grateful if you could confirm  that you will
be disseminating  the information contained in this report and would welcome your response  on
the general issues  that have been raised on the matters  outlined, particularly  in relation  to
inspections of hospitals  built  in a similar way to Queen  Elizabeth  ll Hospital, Wepyn Garden
City, which I understood  from the Trust's legal  representatives  there  were many.

The schedule  requires  a response from you within  56 days  of receipt which I calculate is the
Wednesday  24'n June  2014. Please let me know if there  are difficuliies  in complying with this
timescale  or whether there is anything  you wish to discuss. I am willing  to extend  the deadline  if
there  is good reason  to do so,

Many thanks  for your anticipated assistance  in helping to provide  safe and therapeutic
environments  for all in-patients.

Yours  sincerely

Edward  G
Senior

Responses

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.

Response from Care Quality Commission (PDF)
Care  Quality Commission
Citygate
Gallowgate
Newcastle  upon  Tyne
NE1 4PA

Telephone: 03000 616161
Fax: 03000  61617'1

www,cqc,org.uk

CareQuality
LOmmrssron

Mr Edward  Thomas
HM Senior Coroner - District  of Hertfordshire
The Old  Courthouse
St Albans  Road  East
Hatfield
Hertfordshire  AL10 OES

30 August 2014

BY EMAIL  and POST

Care Quality  Commission
Re: lnquest into the death of Mr Ozan Atasoy

Dear Mr Thomas

Thankyouforyour|etterdatedgApri|2014inwhichyouwrotetousunderthe
provisions of RLgulation 28 of the doroners (lnvestigations) Regulations 2013  in
ielation  to the inquest  into the death  of Mr Ozan Atasoy'

we are extremely saddened  to hear of Mr Atasoy's  death  and of the circumstances
suirounOing  his ieath. We are also grateful  for yggr report  in highlighting  concerns
and issueJ that which can now be ied into the intelligence  monitoring  systems to
irprou"  our regulation  of health  care providers,  and in particular  those  involved  in
mental health  care.
we confirm  that the contents  of your  report, and the issues identified therein,  will be
disseminated  within  the CQC  an'd in particular  in relation to inspections  of hospitals
similar  way to Queen Elizabeth  ll Hospital. The issues will be fed into the
uritt in 
intelligent  monitoring systems  that allow  us to monitor services  and also to plan and
iarry"out  future  insplctions.  lt is intended  that the contents of your  report in this case
will form evidence tnat witi be fed into the key lines of enquiry that form the core of
ourrevisedapproachtothemonitoringandregu|ationofmenta|hea|thservices.

" 

we also confirm our satisfaction with the improvements that have been  implemented
ev t"  trr"t l. t,is case following the deaih of lr/lr Atasoy  in order to address  the
islues that were highlighted durin! the course of the inquest,  and in your report. The
implementation  of inoJe actions ioulo be considered  during  the course  of our next
inspection of the Provider.
we have now  published  our intentions for a more  specialised  a.pproach.  to the
in.p""tionofmenta|healthservicesinboththeNHsandindependentsector.The

1

 changes are set out in a fresh start for the regulation  and inspection  of mental health
services.  We are confident that they will provide a more robust  approach  to
monitoring and inspection  which would not only improve  the identification of the sorts
of issues identified  in your report leading to the death  of Mr Atasoy, but also enhance
the resolution  of those  issues by providers.  We set out an overview of the main
changes  proposed:

.  Full integration  of regulation  and Mental Health Act (MHA)  monitoring;
.  Including Mental  Health Act specialists on all inspections of mental health

services;

.  Inspection  teams of specialist inspectors,  experts by experience and

professional  experts;

.  Ratings  for mental health  services:  services  will be rated outstanding,  good,

requires improvement,  or inadequate;

o  New ways of engaging  with people who use services,  their  careers and

families, during inspections  and at other  times;
.  Greater  focus on community mental  health  services;
.  Making sure we have befter  information  about mental  health  services  and

developing our intelligent  monitoring system  for these services;
o  Looking  at how  people  are  cared for as they  move between  services;
.  Recognising that mental health  treatment  and support  is part of services  in all

sectors; and

.  The appointment of new  Chief  and Deputy Chief  Inspectors of Hospitals. This
includes  the appointment of
t  as Deputy  Chief Inspector  of
Hospitals  with a portfolio of mental health services. lt is hoped that those
appointments  will provide  important specialist  leadership for our regulatory
and MHA  monitoring roles.

It is also hoped  that the changes  will help  improve our identification  of poor mental
health care  and point  to interventions  when  things  need  to be put right. We  have
been testing  out our new methodology  with  "Wave  1" inspections  of NHS  mental
health trusts  occurring  during this and the last financial year. We have  learnt lessons
from those inspections  which  are now being fed into 'Wave 2" inspections to ensure
our regulatory responses  are robust,  proportionate and sustainable.

ln our most recent annual  report on the use of the Mental  Health  Act, we have also
stated our expectation that we hope to see improvements in certain key areas
including an expectation that Commissioners and providers of mental health services
being  proactive in initiating  and embedding  learning  from the deaths of people
subject  to the Mental  Health Act. We expect  to see alignment  of local preventative
and investigative  work with the national findings on mental  health  related deaths.

2

 
 This  includes  emerging  guidance  from  national  bodies and the use of the National
Confidential  Inquiry  into Suicide and Homicide by People with Mental lllness toolkit.
We expect  services to notify us of deaths of detained  patients and patients  who are
on a community  treatment order  at the time  of their  death.

The Commission  has also identified  five key areas of action which  we are confident
will improve the identification  and resolution of the sorts of issues that arose  in this
case.  Those areas of action are in line with, and complement, our strategic  intentions
including recognising that people  in the care of specialist  mental  health seryices  are
a high risk group for suicide and unidentified, poorly treated  or preventable  physical
ill-health. We are concerned  about  how services respond  to, review and report on
deaths,  so we are committing to include the information we hold on deaths  in
psychiatric  detention  in all future annual reports.  We will work with  partners,  including
NHS England and the National confidential lnquiry  into suicide  and homicide  by
people with mental  illness, to look at how  we can do this in a way that offers better
inteiligence  and opportunities for shared learning and preventative  action._ The
Commission will also work with key partners  in developing the Mental  Health  Crisis
Care Concordat.  This will focus  aftention  on the issues  that have been highlighted
around  emergency  mental  health  care.  The Commission  has  committed to delivering
a thematic programme  around the experiences and outcomes of people experiencing
a mental  healih crisis,  and will take this forward  over the rest of 2014 with the
intention  of publishing  a national  report  in shortly  in the autumn.

As part of the new inspection methodology  for specialist mental health services  a set
of standard  key lines of enquiry  ('KLOEs')  have been developed for use in
inspections of mental health  trusts.  lt is intended that a standard set will also  ensure
consistency  of what  we look at under each  domain, which is vital for reaching  a
credible  clmparative  rating.  By way of background  the standard  KLOEs are
underpinned by a series of prompts. Those prompts  will be considered  to be a guide
as to what to inspect in order  to answer  the KLOE.  The main prompts addressing the
sorts  of issues raised  in your report would be as follows:

1. In relation to the height  of the fence, security door opening  mechanisms,  the
door release  and the provision  of ccTV,  the following proposed prompts in
particular  would be considered  within  the context of assessing Safety:

S2.1: Does the design, layout and maintenance  of services enable safe

clinical  Practice?

S2'2: How does  the provider ensure  that people who  Use seryices  are
protected from harm, neglect or abuse?  What safeguarding
'anangements 
are in place? iow are peopte using.seruiges. encouraged
toreportabuseandinvolvedinsafeguardingdecisionsabout
themselves?

52.5: How does  the provider manage positive  isk-management?  ls the
provider risk averse?  How proactive are staff in implementing positive
'isk-management?Arerestictivepracticeswhichhaveanimpacton
the freedom  of peopte who use serv,ces  minimised?

 S3.3  Are there  individually  tailored  care plans in place that help the person

who uses servlces to minimise any isks to them?

In relation to observations,  proposed  prompts  have been designed within the
context  of the evaluating how services  understand  and manage  risk to
persons  using the service.  we intend  for the following  prompts  in particular  to
assist  in assessing  whether  an observation  policy for service  users would be
sufficiently robust,  upto-date  and specific  to service users:
53.1 Are people who use servlces  supported  with comprehensive isk
management  and offered a multi-disciplina4y assessme  nt at an eady
oppoftunitY?

S3.2  Does fhe assessment  include:

.  the  Person's PhYsical  health
.  nsks to self  or others
o  slde  effects  of medication
.  individual  biograPhY
o  involvement  of the  person  themselves rn assesslng nsks

S3.3 Are  there individualty taitored care plans in place that help the person

who  uses services to minimise any isks to them?

In relation to staffing levels,  we do not prescribe the particular number of staff
members that are biing employed to meet patients'  needs, or particular staff-
fatient ratios.  Rather, our asselsment  of whether  essential  standards  of care
"i"  O"ing met in this respect is based on considering the sufficiency  of
f roperty ikill"d .t"ff to meei patients' particular  needs.  The following proposed
brolnpti  would be most  relevant to under the new  methodology  in assessing
whether the provider  ensures  that staffing  levels  and quality of staffing  enables
safe oractice:

s4.1  How does the provider ensure that  staffing  levels are sufficient  to meet

dependencyneedsatanygiventime?Howdoestheproviderensure
that no restictive  practice  takes  place?

S4'2 How often  are agency  staff used?  How does the provider  monitor the
qualityof"e-l"esandnumberofincidentsinseruiceswhichuse
agencY  staff?

s4.3 How does the provider  ensure that staff are skilled and trained  to
provide  safe services?  How does  the provider ensure safe recruitment?

s4.4  llvhat  are staff  srbkness  levels and how does the provider monitor
impact  on other staff  members  and the service provided to people 
.who
uie services?  How does  the provider  monitor sfaff srbkness  /eyels  as
an indicator  of sfaff  sfress?

4

 4. In relation to the issues relating to the provision  of occupational  therapy and
the named nurse system. The following  proposed  prompts  in particular would
be considered  within  the context  of assessing  effectiveness:

Evidence-based,  assessment, care  and treatment  in line with recognised
guidance, tegislation,  standards and best practice,  for example:

o  N\CE/SCIE quality  standards and guidelines
o  Mental Health Act 1983
.  Mental Capacity Act 2005
o  guidance pubtished  by professional  and expett bodies
.  national strategies and programmes
o  Ensuing informed consent
.  Asses  sment of Giltick  competency of children and young  people

.  Assessment and care planning
.  Assessment  and recording of capacity and consent
c  suppofting  people to make choices and informed  consent
o  Review of care and treatment, through:
o  Local audits
.  National audits
.  Monthly  performance dashboards.

Appropriatety quatified,  inducted and competent  permanent,  temporary and
night  staff.

.  Training  and professional  development including:
.  lnduction
.  One-to-one  meetings
o  Appraisals
o  ldentifying leaming needs
o  Coaching  and mentoring
.  Clinical  superuision.

5

 .  Conclusion

We greatly value the intelligence  that you have provided us in your report. The
information contained informs our intelligence  mechanisms,  which in turn directly
influences  the planning  for future  inspections, both in respect  of the Trust specifically
as well as elsewhere. ln broader  terms it also  informs broader policy discussions
within the Commission  in relation  to considerations about  improvements  to our
regulatory  approach.

Please  do not hesitate  to contact us with  any questions or crncerns.

Yours  faithfully

Care  Quality  Commission

o

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