Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0344, written 25 Jul 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 25 Jul 2014 |
|---|---|
| Reference | 2014-0344 |
| Deceased | Stephen Amer |
| Coroner | Edward Thomas |
| Coroner area | Hertfordshire |
| Category | Community health care and emergency services 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, StAlbans Road East, Hatfield, Hertfordshire' AL10 oES DX: 100702 Hatfield Tel: 01707 292780 Fax: 0'1707 897399 MRGRAHAMorNeunv,BlrE#[t?DsBiT-?Htr"il--3lilr,ro*o*oroloMoNs Assistant Coroners 25'n July 2014 INTERNAL POST John Wood Chief Executive Hertfordshire County Council Peg Lane Hertford Hertforshire SG13 3DY Your Ref: t.b.a. Our Ref: 00229-2014 Dear Mr Wood, Re: Stephen Mark AMER, 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 my contact. at the. Care Quality Commission and the University HertforOstrire partnership NHS Trust who carried out a seven day review in connection to their previous contact with Siepnen and with whom there had been discussions over this tragic incident. on the 23'd July 2014, I concluded an inquest into the tragic death of stephen Mark Amer wno was born on lhe 4'n January 1954 and had therefore reacied 60yrs just before he died. please find attached a copy of the Record of Inquest. stephen had i; fact been born at his home address; and was the sole carer of his mother, retiring from him employment as a lorry driver some time previously. In January 2014 his mothe, *as admitted to hospital and stephen was taken by his family to the Accident & Emergency Department at the Lister Hospital where he was found to be malnourished and reported hearing a noise in his head. He was assessed both physically and mentally and was felt to be objectively and subjectively depressed. He was prescribed mirtazapine and to be seen by his doctor and for his family members to oversee his mother's care. stephen was seen by his General Practitioner Dr Turner and saw him subsequently on the 16th January 2014 where ne self reported as being very much better and well supported by his family and that the Cont'd... ... Page Two Stephen Amer responsibility of caring for his 88yr old mother had been too much for him. There had been no previous reports of self-harm and he denied any ideation or intention of self-harm. Stephen's blood pressure was normal and it was the general opinion of all that he was making good progress. A multi-disciplinary case conference had taken place at the Lister Hospital at which it was best interest to be cared for by residential assessment concluded that it was in was initially for respite. However the Social Worker reported subsequently that when seen on her own that she very much expressed the wish and desire to return home and to the Social Worker on her own expressed the view that she was not happy about going into residential care not withstanding that it appeared that she had accepted going into residential care when seen with the family. The assessment of the Social Worker was that had capacity and therefore the provisions of the Mental Capacity Act and Deprivation of Liberty was and her son had never requested a full package of care but the Team not applicable. should be returned home with a full package of care to support l Manager felt that in her perceived wish to be at home and to support her carer, Stephen. This decision was communicated to Stephen by telephone and shortly thereafterwards he took his own life. His body was discovered some two days after contact had been made. who gave evidence at the Inquest. A helpful investigation was carried out by I also was in receipt of a seven day report from the Hertfordshire University Partnership NHS Trust who had recommended that there should be liaison with Social Care concerning a protocol to share intormation concerning seNice users presenting with significant carer fatigue. informed that this protocol was underway and we discussed the issues of consent and how these matters should be communicated. At the Inquest it was debated as to whether it might be helpful:- . To try and ensure that appropriate consents are always given from service users to enable those responsible for providing care to have full information to ensure the most appropriate care is provided. i.e. it would have been helpful for the Adult Care Team to have had Mr Amer's consent for them to have received the information from his General Practitioner and also the Hertfordshire University Partne.ship NHS Trust as to their assessment carried out at the Lister Hospital. . lf as in this case there is a change of plan that the full details of the plan should at least be in embryo form before the change of plan is given to the relevant person, in particular the carer. . The manner of communication should be considered carefully. I would suspect that a face to face communication if possible would be more appropriate as it gives the ability for questions to be answered and full explanations given. lt also enables those informing the decision to be able to gauge the reaction of the recipient of that informataon. It would have been useful if the Adult Care Team had known the content of the Hertfordshire Univerity Partnership NHS Trust assessment and the contact with the GP made on the 16h January 2014. Cont'd.... Page Three Stephen Amer I discussed the above with communicating some of these issues outside Hertfordshire and that is why I lelt it appropriate and he indicated that he would be to write more formally as this letter is then made public through the helpful register kept by the Chief Coroner. I hope therefore that my drawing your attention to this case and to some of the comments made during the Inquest \,vill be helpful for you. The schedule requires a response from you within 56 days of receipt which I calculate is the Friday 19'" September 2014. Please let me know if there are difficulties 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- I look forward to receiving your views in due course. Yours sincerely Edward G fhomas Senior Co
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.
Chief Executive's Office
Chief Executive & Director - Environment: John
iF.,lg/eltrqVF
Coroner's Office
District of Hertfordshire
The Old Courthouse
St Albans Road East
Hatfield
Hertfordshire
ALlO OES
Hertfordshire County Council
CH 0238, County Hall
Hertford SG13 BDE
Fax:
Tel
Minicom:
Contact:
My ref: JW/MGB/1651HCS
Your ref:
Date: 7 August 2014
Dear Mr Thomas
Re: Stephen Mark Amer (Deceased)
Thank you for your letter oJ the 2s July 20'14, issued under Regulation 2g (paragrapn
7(1 ) of schedule 5 of the coroner and Justice Act 2009, followr:ng the inqulst into the
death of Mr Stephen Amer.
I have had the opportunity to discuss the tragic death of this genfleman and the
important observations and recommendations you have raised in your letter with the
Director of the Health & Community Services dLpartment.
During the inquest,
referred to a new protocol which was being
developed with our hearth partners. we entirery agree with your recommendation that
consent arrangements should be included to aliow patient information to be shareo with
social care services (your first bullet point on page 2 of your letter).
Hertfordshire County Council recognises the value of this recommendation which will
also support and promote.the appropriate exchange of information
*" .ou" towards
further integration of health and.social care servicEs and the n"* ,""ponribiliiies set out
,I
October 2014.
th9 C{9 Act (2014). We wiil devetop and introduce a consent form by the 20
"a
we also understand that where there is a change of pran, in this case, refrecting tne
clearly expressed view of Mrs Amer that sne wiineo to return to her home, that the
change of pran is given to the relevant person, in jarticular the
""r"r. | ,"ibi io yo*
:::gid bullet point on.page 2 of your tetter and In the light ot tnis tragic c;se, ine
department has issued a practice instruction to sociar cire starto ciEale oiirpoate a
separate carer's assessment. This must consider the impact of the decision on the
carer and set out in oeta]] tr9 support they wirr require to continue canng-ri-init i. tn"i,
wish' The assessment must arso. addresi continjency plans if for any reason they
oecome unable to care for the vulnerable p"r.onl rh6 bounty counir riilrs*nare tnis
new requirement with hearth.coileagues and request that they foilow tne same practce
when they arrange hospital discharles ot vutneiaote patients or carers outside of social
care referral arrangements.
www. hertsdirect.org
The method of communication must indeed be considered carefully (your third
recommendation). Whilst carers and relatives may choose not to take up the
opportunity of a face to face meeting to discuss discharge arrangements, this remains
the preferred and most effective method of communicating care arrangements. This
arrangement provides a better opportunity to discuss and clarify every aspect of care
and any associated concerns. lt is recognised that mounting pressure on NHS hospital
beds can result in very limited notice of discharge. We will share your conclusions with
local hospital trusts in an effort to ensure that they allow sufficient time to discuss
discharges with relatives / carers face to face.
I would like to thank you for your recommendations which we formally accept. We will
introduce the revised arrangements outlined above and will share these with our health
partners within Hertfordshire. We will also take the opportunity to share your
observations and recommendations more widely with other local authorities through the
network of practice development meetings organised by the Association of Directors of
Adult Social Services.
Yours sincerely
John Wood
Chief Executive & Director - Environment
CORONER'S OFFICE
AREA OF HERTFORDSHIRE
The Old Courthouse, St Albans Road East, Hatfield, Hertfordshire' AL10 oES
DX: 100702 Hatfield
Tel: Ol 707 292780 F a><: 01 707 897399 E-mail:coroner.service@hertfordshire.gov.uk
MR EDWARD THOMAS Senior Coroner MR GRAHAM DANBURY Deputy Coroner
Dr FRANCES CRANFIELD, ALISON GRIEF, EDWARD SOLOMONS ASSiStANt COTONETS
19 August 2014
Mr John Wood
Chief Executive & Director - Environment
CH 0238 County Hall
Hertford
SG13 8DE
Your Ref: JWMGB/1651 HCS
OurRef: 00229-2014
Dear Mr Wood,
Re: Stephen Mark AMER, deceased
Dear Mr Wood
Thank you very much indeed for your letter of the 2/h July and for your prompt response to my
Regulaiion 28 iefter. I have circuiated copies to the Interested Persons according to my list.
Kind regards
Yours sincerely
Edward G
Senior C
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