Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0274, written 20 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 | 20 Jun 2014 |
|---|---|
| Reference | 2014-0274 |
| Deceased | Peter Farebrother |
| Coroner | John Ellery |
| Coroner area | Shropshire, Telford & Wrekin |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
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
THIS REPORT IS BEING SENT TO:
1. Mr Neil Carr Chief Executive
South Stafford and Shropshire Healthcare NHS Foundation Trust
Trust Headquarters
Mellor House
St. George’s Hospital
Corporation Road
Stafford ST16 3AG
CORONER
tam John Penhale Ellery, Senior Coroner, for the coroner area of Shropshire,
Telford & Wrekin
2
3 INVESTIGATION and INQUEST
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.
On the 30" May 2014 |, with a Jury, concluded the Inquest into the death of the
late Peter James FAREBROTHER. The Jury returned a narrative conclusion as
follows:
The deceased Mr Peter James Farebrother took his own life whilst the balance
of his mind was disturbed. In addition it is the decision of the Jury that the risk
of returning Mr Farebrother’s belt and placing Mr Farebrother on general
observation was not fully recognised. These two factors combined contributed
to Mr Farebrother’s death.
at Pine Ward.
5 CORONER’S CONCERNS
is taken. In the circumstances it is my statutory duty to report to you.
CIRCUMSTANCES OF THE DEATH
The late Mr Farebrother had been admitted as an emergency patient to the
Redwood Centre on Oak Ward the 17" July 2013. He was admitted to Holly
Ward 2 days later with the intention of later being admitted to Pine Ward. That
transfer did not take place until! the evening of the 224 August 2013. 2 days
later on the 24" August 2013 Mr Farebrother was found deceased hanging
from a belt ligature attached to the en-suite shower door in his room (room 11)
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
The MATTERS OF CONCERN are as follows. —
(1) The delayed transfer to Pine Ward coming at the end of an evening
shift prior to handover to the night shift.
(2) The failure by the receiving staff on Pine Ward a) during the remainder
of the evening shift or b) at any time during the night shift to recognise
that Mr Farebrother had been on constant watch up to and including
the transfer and that no assessment had taken place changing that
status.
The lack of personal knowledge in the handover procedure and the
limited time the assessing assistant practitioner had at the start of the
morning shift to read Mr Farebrother’s papers.
(3
The assessment may well have resulted in a higher observation level
and the basis on which it was made, consciously or subconsciously, may
have been flawed by the earlier breakdown in information.
(4
The decision to return the belt to Mr Farebrother. It was the same belt
which a) Mr Farebrother later hanged himself with and b) had resulted
in Mr Farebrother having been on constant observation at Holly Ward.
Whilst other ligatures may still have been available to Mr Farebrother
by removing the belt the most obvious ligature would have been
avoided.
(5
The perception that Pine Ward may be ligature free may have lowered
risk awareness. Staff may have felt that the need for higher observation
and/or ligature avoidance had been reduced by the environmental
safety features on Pine Ward itself, whereas the underlying risk
remained.
(6
The sloping door was intended to prevent or reduce the risk of hanging.
Mr Farebrother’s case has indicated that that is not so. No change has
been made to the door and it is therefore possible that this means of
ligature attachment could happen again. The door was manufactured
and delivered for purpose and therefore this concern should also be
shared with the manufacturer. Consideration should also be given
whether there is a need for an en-suite shower door, balancing the
patient’s rights of privacy and dignity over risk of self-harm.
6 ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and | believe
your organisation has 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 15'" August 2014. I, the coroner, may extend the period.
ee
(7
_—
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.
a]
{__
COPIES and PUBLICATION
| have sent a copy of my report to the Chief Coroner and to the following
Interested Persons:
Lanyon Bowdler solicitors for the family
Capsticks solicitors for the Trust
Leaderflush Shapland — door manufacturer's
The Care Quality Commission
PwWNE
1am also under a duty to send the Chief Coroner a copy of your response.
The Chief Coroner may publish either or both ina 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.
20" June 2014 John Penhale Ellery
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