Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0407, written 15 Sep 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 15 Sep 2014 |
|---|---|
| Reference | 2014-0407 |
| Deceased | George Palmer |
| Coroner | Martin Fleming |
| Coroner area | Surrey |
| Category | Other related deaths |
| Organisation named | Surrey and Borders Partnership NHS Foundation Trust |
| 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.
IN THE SURREY CORONER’S COURT IN THE MATTER OF: The Inquest Touching the Death of George Nigel Palmer A Regulation 28 Report — Action to Prevent Future Deaths THIS REPORT IS BEING SENT TO: CMHRS CORONER Martin Fleming Assistant Coroner for Surrey CORONER'S LEGAL POWERS I make this report under the Coroners and Justice Act 2009 paragraph 7, schedule 5 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. INVESTIGATION and INQUEST On 11/4/14 I opened the inquest into the death of George Nigel Palmer, who at the date his death was 20 years old. The inquest was resumed and concluded on 11/9/14. I found that the cause of death to be: la — Hanging I concluded with a narrative conclusion as follows: George Nigel Palmer died by his own hand whilst suffering from anxiety and depression. CIRCUMSTANCES OF THE DEATH On 7/4/14 George Nigel Palmer was found to have died at his home address. He ws suspended from a belt attached to his bedroom door. He had a previous history of depression and anxiety and because of concerns of self harm, he was admitted to the Priory Hospital as an inpatient between 16"-29"/1/14, where he was diagnosed as suffering with a major depressive illness, for which he was prescribed medication. Upon his discharge he was referred to the Crisis Team and CMHRS and was seen at his home address on 11/2/14 when his mental state was thought to have improved, and upon 20/2/14 when he was assessed as looking forward to starting at Durham University. Because of his RT 4283 1 perceived improvement in his mental health, and his movement to Durham, he was discharged from the CMHRS. Although George agreed to provide the contact details of his GP in Durham he did not forward them in order to facilitate possible further mental health support. CORONER’S CONCERNS During the inques' Registered Mental Health Nurse, provided helpful evidence and the following concerns were highlighted: - e Discharge follow up mechanisms to contact patients who transfer to a different area to ensure that they are offered continuity of support. ¢ Appropriateness of follow up letters to the patient in the event of non-contact. I would ask that you consider giving further consideration to the above to ensure that there is no further repetition. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe that the CMHRS has the power to take action YOUR RESPONSE You are under a duty to respond to this report within 56 days of its date; 1 may extend that period on request. Your response must contain details of action taken or proposed to be taken, setting out the timetable for such action. Otherwise you must explain why no action is proposed. COPIES - GP — Consultant Psychiatrist Chief Coroner Signed: Martin Fleming — Assistant Coroner for Surrey DATED this 15" September 2015 RT4283 9
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.
Surrey and Borders Partnership NHS) NHS Foundation Trust Trust Headquarters 18 Mole Business Park Randalls Road, Leatherhead Surrey 26 06 2015 KT22 7AD Martin Fleming Tel: 01372 216288 Assistant Coroner in Surrey c-mail: i Dear Mr Fleming Inquest into the death of George Palmer - REGULATION 28 REPORT TO PREVENT FUTURE DEATHS Further to the conclusion of the inquest into Mr Palmer’s death on 11 September 2014, you wrote to Surrey and Borders Partnership NHS Foundation Trust in accordance with the Regulation 28 report to prevent future deaths, stating that during the course of the inquest the evidence revealed matters giving rise to concern. We would like to take this opportunity to offer our sincere condolences to Mr Palmer's family for their loss. The areas of concern you raised that relate to our Trust and our responses are detailed below: Discharge follow up mechanisms to contact patients who transfer to a different area to ensure that they are offered continuity of support. Our mechanisms to contact Mr Palmer and share information with his GP when he moved to a new area for university did not work as well as we would have expected, for this we are very sorry. Further to the Inquest, we have reviewed the processes relating to how this Home Treatment Team shares information with new service providers in particular when people who are still in need of mental health services are discharged from our services due to their relocation to other parts of the country. Staff in the Home Treatment Team have been reminded of the local discharge and follow-up procedures for people discharged from Home Treatment Team. As per our local protocol, our staff will ensure that when they are made aware of the eminent relocation of a person who still requires use of mental health services, they will request from the person, information relating to their new location of residence including GP details. This is to enable us to refer to another provider of Mental Health Services local to them. If the person is yet to be registered with a new GP, we will refer to local services in that new location and also inform their original GP of the discharge and any further referrals for completeness. If a person is temporarily registered with a GP in this area, then their original GP is also notified. For a better life Trust Headquarters, 18 Mole Business Park, Leatherhead, Surrey KT22 7AD T_0300 55 55 222 F_01372 217111 wwwsabp.nhs.uk We will share the full discharge summary with the GP within 7 days of the discharge. We also share a short and precise Discharge Notification with the GP which is sent the same day via fax and documented in the progress notes as such and uploaded to Clinical Documentation in our Electronic Patient Record system. This document gives key and pertinent facts. For example date of admission and discharge to Home Treatment Team (HTT), current medication, and follow-up. Appropriateness of follow up letters to the patient in the event of non-contact. We accept that follow-up letters alone are not sufficient as a means of contact or a way to ensure that people are receiving mental health support in new areas of residence. It is at times quite challenging for us to ensure that a person who has relocated to a new area is receiving the right level of Mental Health support if they have not registered with a GP as the majority of teams are GP aligned. We however work to ensure that people are well supported; for example if a patient using our service chooses to visit family/friends in another area for a period of time, then we proactively ask if they would like mental health input whilst visiting another and a referral is made, supplying information such as current medication prescribed, risk assessment and Care plans. We have logged the issues outlined in the Regulation 28 report to our corporate action plan and learning from this will be shared with the rest of the organisation through our quarterly serious incident learning events. We would like to offer our sincere condolences again to the Palmer family for their loss. We hope that the steps we have taken as outlined above assure you and Mr Palmer's family that we have learnt and continue to learn from Mr Palmer's death. Please do not hesitate to contact me or Billy Hatifani, Director of Risk & Safety/Deputy Director of Nursing/Emergency Planning Lead if you require any further information. Yours sincerely P| Deputy Chief Executive, Director Quality, Director of Nursing cc Fiona Edwards, Chief Executive
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