Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0377, written 18 Aug 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 18 Aug 2014 |
|---|---|
| Reference | 2014-0377 |
| Deceased | Jeffrey Gash |
| Coroner | Andrew Tweddle |
| Coroner area | County Durham & Darlington |
| 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 THIS REPORT !S BEING SENT TO: 1. The Chief Executive, Tees, Esk and Wear Valley NHS Trust CORONER lam Andrew Tweddle , Senior Coroner, for the Coroner area of County Durham and 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. (see attached sheet) INVESTIGATION and INQUEST On 3” October 2014 | commenced an investigation into the death of Jeffrey Gash aged 46 yrs. The investigation concluded at the end of the inquest on 5" August 2014. The conclusion of the inquest was “intentionally took his own life” CIRCUMSTANCES OF THE DEATH 1. The deceased, following a referral from his GP, met with the Crisis Team on 29" August 2013. He was subsequently seen by his GP again and a Consultant Psychiatrist. 2. On27" September 2014 the GP received a telephone call from the deceased's wife saying that he was distressed and was hearing voices. The GP contacted the Crisis Team, spoke to a nurse who gave advice which resulted in the GP making a home visit to assess the situation before further contact was made with the Crisis Team. 3. The Crisis Team nurse, after speaking with colleagues decided not to make a home visit because of personal safety risks and spoke with the deceased on the telephone to discuss his problems, invite him to attend West Park Hospital and when he declined, gave further contact information to assist. 4. On 28" September, the same Crisis Team nurse received a further telephone call from the deceased stating that he was feeling worse, had spoken to the Samaritans but in evidence, the nurse believed this was a positive not a negative position, as he was seeking assistance, sharing his concerns and she decided not to consider taking matters further not requesting a face to face visit or escalating the matter further. The deceased hung himself on 30" September 2013. The deceased left a note and in this he said “ You no | went to see the doctors at West Park Hospital | was hurting every day but they weren't interested”. an 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. — eile SUMMARY OF MATTERS OF CONCERN] The Crisis Team nurse accepted in evidence that she had not been as forceful as she could and should have been to explore with the deceased his new symptoms, auditory hallucinations, hearing voices. This evidences a lack of training and understanding of the nature of and importance of an appropriate level of telephone assessment 2. No evidence was provided at the inquest to indicate a formal Trust policy on when to decline home visits on the grounds of personal safety and security and the nurse relied upon being told of concerns about visiting this property from colleagues but did not record the same or any explanation for her decision. The absence of a clear policy and a policy for recording decisions made or understanding and training thereon is an area of concern 3. Notwithstanding the fact that the deceased declined to attend the hospital for a face to face interview, insufficient weight was given to the reason therefore and whether domestic and other pressures were militating against him attending were not properly considered, if at all. 4. Given that there was an insufficiency of enquiry into the deceased's state of mind and in particular, a failure to further explore the issue of him claiming to hear voices, on inadequate assessment of risk was undertaken and it was | accepted by the Trust in evidence that there ought to have been a face to face | consultation with the deceased and that had he not agreed to it voluntarily, then there ought to have been a compulsory assessment. 5. The clinical risk assessment and management policy document (Version 5) which was presented in evidence fails to clarify the nature and detail of what form of risk assessment needs to be completed when a none in-person face to face is being undertaken. Thus, the notes entered on the PARIS system were unclear as to their author's view of risk of self harm where it was accepted in evidence that full details of the assessment of risk and its conclusion are central to the Crisis Team process. The Trust has carried out an SUI. Certain | recommendations have been made and are being implemented. The inquest however, as evidenced above, revealed other issues not dealt with by the SUI and therefore a complete re-evaluation of the deceased’s contact with the Trust should be undertaken taking into account the evidence given at the inquest so that a complete overview of Trust policy dealing with the above matters and any other such review might uncover can be considered by management and if agreed, implemented. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you and your organisation 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 13" October 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 Persons Messrs Longden Walker and Renney Messrs Ward Hadaway 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. 18” August 2 SIGNED... A TWEDDLE LLB, H M CORONER COUNTY DURHAM AND DARLINGTON SCHEDULE 5 paragraph 7 ACTION TO PREVENT OTHER DEATHS 1)Where— (a)a senior coroner has been conducting an investigation under this Part into a person's death, (b)anything revealed by the investigation gives rise to a concern that circumstances creating a risk of other deaths will occur, or will continue to exist, in the future, and (c)in the coroner's opinion, action should be taken to prevent the occurrence or continuation of such circumstances, or to eliminate or reduce the risk of death created by such circumstances, the coroner must report the matter to a person who the coroner believes may have power to take such action. (2)A person to whom a senior coroner makes a report under this paragraph must give the senior coroner a written response to it. (3)A copy of a report under this paragraph, and of the response to it, must be sent to the Chief Coroner. Regulations 28 and 29 Report on action to prevent other deaths 28.—(1) This regulation applies where a coroner is under a duty under paragraph 7(1) of Schedule 5 to make a report to prevent other deaths. (2) In this regulation, a reference to “a report” means a report to prevent other deaths made by the coroner. (3) A report may not be made until the coroner has considered all the documents, evidence and information that in the opinion of the coroner are relevant to the investigation. (4) The coroner— (a) must send a copy of the report to the Chief Coroner and every interested person who in the coroner's opinion should receive it; (b) must send a copy of the report to the appropriate Local Safeguarding Children Board (which has the same meaning as in regulation 24(3)) where the coroner believes the deceased was under the age of 18; and (c) may send a copy of the report to any other person who the coroner believes may find it useful or of interest. (5) On receipt of a report the Chief Coroner may— (a) publish a copy of the report, or a summary of it, in such manner as the Chief Coroner thinks fit; and (b) send a copy of the report to any person who the Chief Coroner believes may find it useful or of interest. Response to a report on action to prevent other deaths 29.—(1) This regulation applies where a person is under a duty to give a response to a report to prevent other deaths made in accordance with paragraph 7(1) of Schedule 5. (2) In this regulation, a reference to “a report” means a report to prevent other deaths made by the coroner. (3) The response to a report must contain— (a) details of any action that has been taken or which it is proposed will be taken by the person giving the response or any other person whether in response to the report or otherwise and set out a timetable of the action taken or proposed to be taken; or (b) an explanation as to why no action is proposed. (4) The response must be provided to the coroner who made the report within 56 days of the date on which the report is sent. (5) The coroner who made the report may extend the period referred to in paragraph (4) (even if an application for extension is made after the time for compliance has expired). (6) On receipt of a response to a report the coroner— (a) must send a copy of the response to the report to the Chief Coroner; (b) must send a copy to any interested persons who in the coroner's opinion should receive it; and (c) may send a copy of the response to any other person who the coroner believes may find it useful or of interest. (7) On receipt of a copy under paragraph (6)(a) the Chief Coroner may— (a) publish a copy of the response, or a summary of it, in such manner as the Chief Coroner thinks fit; and (b) send a copy of the response to any person who the Chief Coroner believes may find it useful or of interest (other than a person who has been sent a copy of the response under paragraph (6)(b) or (c)). (8) A person giving a response to a report may make written representations to the coroner about— (a) the release of the response; or (b) the publication of the response. (9) Representations under paragraph (8) must be made to the coroner no later than the time when the response to the report to prevent other deaths is provided to the coroner under paragraph (4). (10) The coroner must pass any representations made under paragraph (8) to the Chief Coroner who may then consider those representations and decide whether there should be any restrictions on the release or publication of the response.
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.
Tees, Esk and Wear Valleys [i'/eA3 NHS Foundation Trust West Park Hospital Edward Pease Way Darlington DL2 2TS Direct Line: Fax: 13 October 2014 By emali: Andrew Tweddle LL.B. H M Senior Coroner for County Durham and Darlington H M Coroners Office PO Box 282 Bishop Auckland County Durham DL14 4FY Dear Mr Tweddle Regulation 28 Report in respect of the death of Mr Jeffrey Gash Thank you for your Regulation 28 report dated 18 August 2014 in respect of the above individual and your findings from the inquest into his death. | have tried to address each of your concems in turn below, and have summarised key actions (with timescales) in the appended action plan. 1. The Crisis Team nurse accepted in evidence (that she) should have been more forceful and detalied in exploring with the deceased his new symptoms, auditory haliucinations and hearing voices which evidences a tack of training and understanding of the nature of and Importance of an appropriate ievei of telephone assessment. As you have described, the individual nurse involved in the care of Mr Gash recognised in the inquest that she should have been more detailed in her questioning of him in relation to specific symptoms. This individual has, since the inquest, spent some time reflecting on this with her clinical supervisor. In addition, from September 2013 to January 2014 the individual nurse went through a period of informal capability management. During this time she did not undertake the shift co-ordinator role responsibilities and worked all shifts alongside a more senior and experienced member of the team. She observed best practice assessments and then her assessment practice was observed and evaluated. Once the observing expert clinician, Advanced Practitioner and Team Manager were all satsified that she had acheived the appropriate levels of competence she was able to resume the shift co-ordinator role. Since that time, periodic checks of her assessments (and assessments done by the rest of the team) have been undertaken by the Consultant Psychiatrist to provide assurance that they are of appropriate quality. This has also enabled us to provide specific feedback to staff as needed to help them develop and improve. We are now assured that the individual nurse has increased her competence and knowledge in telephone assessment skills together with an overall improvement in team performance. . No evidence was provided at the Inquest to Indicate a formai Trust policy on when to decline home visits on the grounds of personal safety and security and the nurse relied upon being told of concerns about visiting this property from colleagues but did not record the same or any explanation for her decision. The absence of a clear policy and a policy for recording decisions made or understanding and training thereon is an area of concern. In relation to your specific comments about Trust policy, the Trust Clinical Risk Assesment and Management (CRAM) policy outlines the responsibilities for staff to determine potential risks and the need to document these within the clinical record. The risks identified in relation to visting Mr Gash at home should have been assessed within the gudiance provided by that policy and recorded in the clinical record. Decisions about making lone or accompanied visits to the home should have been recorded in the clinical record and the processes in the Trust Health and Safety workbook also provide guidance on assessing whether a home visit is appropriate or not. The Trust also has a Lone Working Procedure which should be completed for all staff who may in the course of their duties have periods where they are working alone including in the context of a high risk visit. This is to some extent addressed within the SUI report where it is documented that a more assertive approach may have helped within the engagement findings. The policy lead for these areas will be asked to review the relevant policy against your findings and ensure that these are fully taken into account and an implementation plan produced accordingly. In relation to recording the information from colleagues, and the individual nurse’s decision making on the shift in question, there is already an ‘alerts’ section in our electronic care record which staff are asked to use to document risks in a way that this information is available to all staff working with a specific patient. The Team Manager has previously highlighted the importance of recording this with the team, but since Mr Gash’s inquest has further reinforced this via team meetings. In addition, the Head of Service for Durham and Darlington AMH Services has asked the Crisis Team Manager to share your recomendations with the Specialty’s Acute Care Group in order that the Trust standard operational policy for Crisis Teams can be strengthened accordingly. | also acknowledge the conclusions from the inquest that further options may have been available in the absence of Mr Gash agreeing to see the crisis team at the hospital base, and indeed am aware of instances where staff have used alternative venues for appointments. Staff have been reminded of the need to explore and utilise alternative appointment venues. . Notwithstanding the fact that the deceased declined to attend the hospital for a face to face interview, insufficient weight was given to the reason therefore and whether domestic and other pressures were militating against him attending were not properly considered, If at all. . Given that there was an insufficiency of enquiry Into the deceased's state of mind and in particuiar a failure to further expiore the issue of him claiming to hear voices, an Inadequate assessment of risk was undertaken and it was accepted by the Trust in evidence that there ought to have been a face to face consultation with the deceased and that had he not agreed to it voluntarily, then there ought to have been a compulsory assessment Since Mr Gash’'s sad death, the individual nurse has critically reflected upon this at length with the team manager during her period of informal capability management described under point 1 above. | agree that more in-depth exploration of his reasons for not wishing to attend should have been undertaken. The Trust Did Not Attend policy does highlight that the nurse should have contacted the GP immediately to agree a management plan, in situations where high risks have potentially been identified. As noted above, the individual nurse has undergone a period of observed practice such that the Advanced Practitioner and Team Manager are now satisfied that she would now manage this situation differently, in that issues would be explored in more depth. We are also confident that she would now, and has been shown to, use colleagues within the team for additional opinions, and make better use of medical staff for consideration when a formal assessment under the Mental Health Act may be requried. Your recommendations in relation to this have been shared with the team as a whole to ensure that their practice reflects the specific actions we have completed with the individual nurse. . The clinical risk assessment and management policy document (version 5) which was presented in evidence faiis to clarify the nature and detail of what form of risk assessment needs to be completed when a non in-person face to face is being undertaken. Thus, the notes entered on the PARIS system were unclear as to their author’s view of the risk of self harm where it was accepted in evidence that full detalis of the assessment of risk and its conciusion are central to the crisis team process. The Trust has carried out an SUI. Certain recommendations have been made and are impiemented. The inquest, however, as evidenced above, reveaied other issues not deait with by the SUi and therefore a complete re-evaiuation of the deceased’s contact with the Trust should be undertaken taking into account the evidence given at the inquest so that a compiete overview of Trust policy dealing with the above matters and any other such review might uncover can be considered by management and If agreed, Impiemented. A further review of the Trust’s contact with Mr Gash will be undertaken, incorporating other matters arising from the inquest. The review will include the efficacy and relevance of the current Trust policy guidance and an analysis of compliance with that guidance included in the review. A Trustwide review of the clinical risk (CRAM) policy and practice is currently underway, with initial reports due in the spring; the information from this Serious Untoward Incident investigation and the inquest will be fed into that review. Further training and development in suicide prevention is planned for early next year. lmplementation plans for the new policy and the training will be evaluted to ensure compliance. In conclusion, the Adult Mental Health Directorate had begun several pieces of improvement work prior to the inquest to address some of the concerns, and can only apologise if these were not clear through the evidence given by staff. However there are also a number of Trust-wide issues highlighted through the inquest process. which will take a little longer to fully address. The implementation of the actions relating specifically to issues within the gift of the Adutt Mental Health Directorate within the action plan attached will be monitored via the Directorate’s Quality Assurance Group on a monthly basis to ensure completion. In addition review of the effectiveness of the actions, and policy compliance will be reported to the Locality Management and Governance Board. Any Trust-wide actions identified will be allocated to an appropriate action plan owner and monitored by the Patient Safety Team by their governance processes to ensure they are completed to an appropriate standard. The Diretorate Quality Assurance Group processes will also ensure that the lessons from this case and associated teaming are shared across other in-patient areas and crisis teams in order that they can assure us that similar issues should not occur elsewhere. The Trust has corporate processes to both monitor completion of serious incident action plans and to audit the effectiveness of those actions in creating change and improvement. | hope that the information contained here, and in the amended action pian attached, provides you with the necessary assurance you require. Yours sincerely Martin Barkley Chief Executive
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