Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0268, written 13 Jun 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 13 Jun 2014 |
|---|---|
| Reference | 2014-0268 |
| Deceased | Alun Sheppard |
| Coroner | John Gittins |
| Coroner area | North Wales (East & Central) |
| 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 (1) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: BCUHB, Ysbyty Gwynedd, Penrhosgarnedd, Bangor, Gwynedd LL57 2PW i CORONER lam JOHN ADRIAN GITTINS, senior coroner, for the coroner area of North Wales (East and Central)] 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 the 10" of January 2014 | commenced an investigation into the death of Alun Sheppard (DOB 10.01.1965 DOD 10.01.2014). The investigation concluded at the end of the inquest on the 3° of June 2014 and | recorded an narrative conclusion in respect of the death in the following terms :- On the 21" of December 2013 at The Fields, Holt, Wrexham the Deceased took a kitchen knife and inflicted upon himself a number of stab wounds. Although he initially survived these injuries and was treated for them, his condition deteriorated resulting in his death at the Maelor Hospital Wrexham on the 10" of January 2014 4 | CIRCUMSTANCES OF THE DEATH The Circumstances of the death are as set out in the narrative conclusion appearing in paragraph 3 hereof. 5 | CORONER’S CONCERNS During the course of the inquest, evidence given by the family of the Deceased indicated that although Mr Sheppard had been receiving treatment for a condition diagnosed as Paranoid Psychosis, they were unaware of this true extent of his mental health issues and consequently were unable to fully support Mr Sheppard and to take appropriate steps which may have mitigate the opportunity for him to self harm. 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 :- Effectively the concern in this case revolves around whether the Health Board are able to balance the patient's right to confidentiality whilst also seeking to optimize the prospect of recovery by facilitating familial support. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe your organisations 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 gh August 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 Person — EEE (brother of the Deceased) | 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] 13" June 2014 [SIGNED BY CORONER] dun Gettin
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.
YMR Bangor, Gwynedd, LL57 2PW ia) Las GIG Bwrdd lechyd Prifysgol Ysbyty Gwynedd, Penrhosgarnedd, #) H Betsi Cadwaladr sooeeeenccntcnencennntenenenent 4 WALES University Health Board Gwynedd Hospital, Penrhosgarnedd, Bangor, Gwynedd, LL57 2PW Mr John A Gittins Ein cyt / Our ref: EINQ-1582 H M Coroner for North Wales (East and Eich cyf / Your ref: Central) County Hall Rhif Ffon/ Phone: ®: Wynnstay Road Gofynnwch am / Ask for: FY Ruthin Ffacs | Fax: LL15 1YN E-bost / Email: Dyddiad / Date: 2 September 2014 Dear Mr Gittins Re: Report for the Prevention of Future Deaths — Alun Sheppard Thank you for your letter dated 13 June 2014 enclosing the Report for the Prevention of Future Deaths in accordance with Regulation 28 of the Coroners’ (Investigations) Regulations 2013. Firstly, on behalf of the Health Board, | would like to forward our sincere condolences to Mr Sheppard's family for their loss. | note the matter of concern to be: “Effectively the concern in this case revolves around whether the Health Board is able to balance the patient's right to confidentiality whilst also seeking to optimise the prospect of recovery by facilitating familial support’. | totally agree that the prospect of any patient's recovery is improved with familial support. Mental health practitioners routinely encourage service users to engage with their family members and increase their support networks. The policy of the Health Board is to use a confidentiality form, a copy of which fs enclosed. lf a patient has capacity to make decisions about whether or not families or carers are involved in a patient's care planning and care, services are obliged to respect that decision unless there is an overriding public interest that merits disclosure of information. Ifa patient makes a capacious decision not to involve their family or carers in their care, mental health practitioners still have a responsibility to listen to any concerns and act upon them accordingly. If a patient is deemed to lack capacity, a disclosure of information needs to be based on a Best Interest Decision. If you feel it would be helpful to discuss this response in more detail, please contact MRR ME Chief of Staff for Mental Health and Learning Disabilities Clinical Pr Group. a Cyfeiriad Gohebiaeth ar gyfer y Cadeirydd a’r Prif Weithredwr / Correspondence address for Chairman and Chief Executive: Swyddfa'r Gweithredwyr / Executives’ Office, Ysbyty Gwynedd, Penrhosgarnedd, Bangor, Gwynedd LL57 2PW Gwefan: www.pbc.cymru.nhs.uk / Web: www.bcu.wales.nhs.uk ON G IG Bwrdd lechyd Prifysgol Bets! Cadwaladr U 24 . i S University Health Board WALES | hope that this response has provided you with the reassurance you sought when issuing the Regulation 28 Report. Yours sincerely, Signed by the Executive Director of Nursing and Midwifery on behalf of the Chief Executive Encl
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