Prevention of Future Deaths reports · 2014
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 report | 9 Apr 2014 |
|---|---|
| Reference | 2014-0166 |
| Deceased | Ozan Atasoy |
| Coroner | Edward Thomas |
| Coroner area | Hertfordshire |
| 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.
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
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.
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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