Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0254, written 28 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 | 28 May 2014 |
|---|---|
| Reference | 2014-0254 |
| Deceased | Laura Page |
| Coroner | Lydia Brown |
| Coroner area | Leicester City & South Leicestershire |
| Category | Community health care and emergency services 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.
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 |S BEING SENT TO: 4. Chief Executive, Leicester Partnership Trust NHS Trust 1 | CORONER | am Lydia Brown assistant coroner, for the coroner area of Leicester City and Leicestershire South 2 | 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. 3. | INVESTIGATION and INQUEST On 12 December 2012 | commenced an investigation into the death of Laura Page 34 years of age. The investigation concluded at the end of the inquest on 21 May 2014. The conclusion of the inquest was: Laura Page experienced a combination of social stresses in November 2012 that led her to seek medical support. Despite clear recognition of her needs the care plan was not carried out by the community team and Laura took an overdose that led to inpatient secure psychiatric care in the Bradgate Unit for 5 days. Her discharge was not completed when she left the unit and was in any event based on inadequate inter-agency communication. No concerns were recognised by any Trust professional in relation to her absence. Laura went home on 4" December 2012, took a substantial overdose and despite seeking medical attention, she died from the consequences of this at 2035 hours in Leicester Royal Infirmary. 4 | CIRCUMSTANCES OF THE DEATH See above 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. — Ms Page was referred by her GP to the crisis team, who carried out an initial assessment and agreed daily home visits. On 3 separate occasions, different clinicians attended the home address but could not gain access, could not leave a note and did not attempt to contact the client as they had no telephone contact details. These failed visits were not brought to the attention of the shift supervisor that day or the Consultant team meeting the following morning. (1) The clinician response to failed visits is not robust. Further practical efforts could be considered, including door access key fobs where appropriate. (2) The escalation policy should be reviewed to consider specific time targets for action. (3) The threshold for requesting a welfare check should be reconsidered. (4) An analysis of failed visits and untoward outcomes across the service could be maintained and audited to ensure lessons are learnt and best practice shared. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you 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 23 July 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 mother sister son }~ Guardian for daughter Leicestershire Partnership Trust Leicestershire County Council G- General Practitioner | 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. [DATE] 1g Mon WK
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.
Leicestershire Partnership NHS Trust P| eat eee Lakeside House 4 Smith Wi Your ref, CEM/DEk/03265-2012 ous Park Our ref; PeM/kd/L242 Enderby Leicester LE19 18S. 21 July 2014 Tel: 0116 295 0030 Fax: 0116 295 0842 Z i ’ : www.leicspt.nhs uk H.M. Coroner for Leicester City & South Leicestershire The Town Hall Town Hall Square Leicester LE1 9BG Dear Mrs Brown, Regulation 28 of the Coroners’ rules re: Laura Page Further to your Report dated 28 May 2014 in accordance with paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 | offer the following response. We have investigated the matter that you raised relating to concerns about how the crisis team respond to failed visits, including the escalation of concerns and the threshold for requesting a welfare check. Leicestershire Partnership NHS Trust takes these matters very seriously and | hope that you are satisfied that we have taken appropriate measures to prevent such an occurrence happening again. The following actions have been taken: (1) The clinician response to failed visits is not robust. Further practical efforts could be considered, including door access key fobs where appropriate. The teams within the Crisis Service were notified of the outcome and the contents of the Regulation 28 at their team meetings and via email communication. A clear process has also been developed and put in place to ensure that all failed visits are dealt with following the same process. This 's detailed in the attached flow chart (Annex), All staff have been issued a copy of the flow chart and the process discussed within team meetings. In addition the Operational Procedure for Crisis Resolution Team has been updated and re-issued to all staff to reflect this process (Appendix). By way of explanation of the changes incorporated within the Flowchart we would draw your attention to the following: Chair: Professor David Chiddick CBE Chief Executive: Dr Peter Miller The first visit by the team should where possible be carried out by a registered mental health practitioner (a member of staff who is registered with a professional body). This is to ensure that ongoing care can be planned If it is not possible to secure the engagement of a qualified practitioner, then this must be escalated to the Team Manager or Service Manager who will consider the relevant issues and have the authority to redeploy staff to assist the team by providing a qualified practitioner to visit. This will be documented. In terms of the issue of key fobs, this is not a practical resolution to the problem of a failure to engage with the patient. However, the Police do have access to such fobs and consideration has been given to this in terms of obtaining access. (2) The escalation policy should be reviewed to consider specific time targets for action. This has been undertaken and the flowchart states specific time targets for action. (3) The threshold for requesting a welfare check should be reconsidered. This has been considered and the flowchart clarifies the threshold for requesting a welfare check. (4) An analysis of failed visits and untoward outcomes across the service could be maintained and audited to ensure lessons are learnt and best practice shared. The Crisis Service Manager is now undertaking a weekly audit check on failed visits to assure compliance in line with the new process, and is monitored through key line performance indicators. We are aware that the difficulty in this case was essentially one of communication. We have endeavoured to make it clear to staff that they must do all that they can to engage with a patient. Where they are unable to do so, this must be dealt with in accordance with the Operational Procedure. This will enhance communication within the team so that a failure to engage will be seen by the relevant team. This will assist in the handover meetings. Yours sincerely | / YQ ASL = r Peter Miller Chief Executive a AL “b, Chair; Professor David Chiddick CBE Chief Executive: Dr Peter Miller POS/y, = Hoy, Pe, > say
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