Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0248, written 29 May 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 29 May 2014 |
|---|---|
| Reference | 2014-0248 |
| Deceased | Stephen Ward |
| Coroner | Mary Hassell |
| Coroner area | Inner North London |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Camden and Islington NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Regulation 28: Prevention of Future Deaths report
Stephen Anthony WARD (died 28.02.14)
THIS REPORT IS BEING SENT TO:
1. Ms Wendy Wallace
Chief Executive
Camden & Islington NHS Foundation Trust
4th Floor, East Wing
St Pancras Hospital
4 St Pancras Way
London NW1 0PE
1
CORONER
I am: Coroner ME Hassell
Senior Coroner
Inner North London
St Pancras Coroner’s Court
Camley Street
London N1C 4PP
2
CORONER’S LEGAL POWERS
I make this report under the Coroners and Justice Act 2009,
paragraph 7, Schedule 5, and
The Coroners (Investigations) Regulations 2013,
regulations 28 and 29.
3
INVESTIGATION and INQUEST
On 06.03.14, I commenced an investigation into the death of Stephen
Anthony Ward, aged 41 years. The investigation concluded at the end of
the inquest yesterday. I made a determination that Stephen Ward took
his own life by hanging.
4
CIRCUMSTANCES OF THE DEATH
Mr Ward had a long history of depression and other mental health
problems, but he deteriorated in 2013, following the death of his mother
at the hands of his step father, and his step father’s suicide by hanging.
1
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.
Mr Ward had a great deal of input from a variety of mental health
services, including daily visits/telephone calls from the South Camden
Crisis Resolution Team in the period immediately leading up to his death.
When he did not attend the South Camden Recovery Centre at Jules
Thorn, or respond to telephone messages or an unannounced crisis team
visit on Thursday, 27 February (the day before he was found hanging by
a close friend), members of the crisis team were worried.
They did not immediately ask police to conduct a welfare visit, which I
appreciate was a matter of clinical judgement. They were influenced in
particular by the fact that their visit was not scheduled and so he might
have been out, as he had been on a previous occasion.
However, at around 7.30pm on Thursday, 27 February, a member of the
crisis team placed a call to police asking for a welfare check to be carried
out. What concerns me is that, when the police did not call back within
an hour or two, nobody from the crisis team followed this up with the
police.
The next contact was at around 8.15am on the morning of Friday, 28
February, when the police rang the crisis team to say that they were
outside Mr Ward’s building and could not locate his flat.
In fact, Mr Ward’s friend had by this time found him hanging.
Mr Ward did not have any personal contact with anyone after Tuesday,
25 February, so by the time the alarm was raised on Thursday evening,
he might well have already died. However, he might not. In any event,
following up with the police might be critical for another person in his
position.
It seems that the team would benefit from a clear protocol about the
required action once police have been contacted and I invite you to
consider this.
6
ACTION SHOULD BE TAKEN
In my opinion, action should be taken to prevent future deaths and I
2
believe that you and your organisation have the power to take such
action.
7
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date
of this report, namely by 25.07.14. 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 following.
HHJ Peter Thornton QC, the Chief Coroner of England & Wales
brothers of Stephen Ward
friend of Stephen Ward
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
interest. You may make
representations to me, the Senior Coroner, at the time of your response,
about the release or the publication of your response by the Chief
Coroner.
it useful or of
find
9
DATE SIGNED BY SENIOR CORONER
29.05.14
3
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.
Page 1 of 57 Camden and Islington INHS NHS Foundation Trust Chief Executive Office Camden & Islington NHS Foundation Trust St Pancras Hospital 4 St Pancras Way London NW1 OPE Tel: 020 3317 3224 Fax: 020 3317 3230 chief.executive@candi.nhs.uk www.candi.nhs.uk 224 July 2014 Coroner ME Hassell Senior Coroner Inner North London St Pancras Coroner’s Court Camley Street London N1C 4PP Dear Coroner Hassell, Re: Stephen Anthony WARD (died 28.02.14) | write further to your report on the above dated 29" May 2014. In this report you state that “it seems that the team (South Camden Crisis Team) would benefit from a clear protocol about the required action once police have been contacted and | invite you to consider this”. Further to your report the Trust has considered the issues raised. Attached is a guidance note that has been drawn up to clarify arrangements across all community mental health teams. This has been developed following a review of practice already in place within services. It requires that requests for checks should be followed up within six hours of them being made. This guidance note is now to be developed into a full protocol for use across the organisation. The process of developing this will include further work with colleagues from the Metropolitan Police. The guidance is due to be issued to staff across the organisation on 21° July 2014, with the ratification of the full protocol due at the Trust Quality Committee in September 2014 for formal issuing as a Trust Protocol by 1% October 2014. | Your partner in CRI Chief Executive: Wendy Wallace care & improvement 2d C&l is an NHS trust providing treatment and social care for mental ill-health and S&2Camden ® ISLINGTON substance in adults misuse in partnership with Camden and Islington councils. Page 2 of 57 NHS) The procedure in Substance Misuse services is different, due to the different nature of the client group and treatment interventions, and a copy of current policy in these services is also attached for your information. | trust that this addresses the concerns you have raised. Yours sincerely, Wendy Wallace Chief Executive
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