Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0445, written 15 Oct 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 Oct 2014 |
|---|---|
| Reference | 2014-0445 |
| Deceased | Lucasz Lewandowski |
| Coroner | Lisa Hashmi |
| Coroner area | Manchester North |
| Category | Community health care and emergency services related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
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: 1. Chief Constable, Greater Manchester Police 2. | the Practice Director, Green Surgery, Manchester 3. MEDACS Healthcare 1 CORONER lam Mrs L J Hashmi, Assistant Coroner, for the coroner area of Greater Manchester North 2 CORONER’S LEGAL POWERS | make this report under paragraph 7, Schedule 5, of the Coroner's and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 3 INVESTIGATION and INQUEST On the 29" September 2014 | commenced an investigation into the death of Lucasz Lewandowski. The conclusion at inquest was Misadventure. The medical cause of death was 1a) Severe Traumatic Head Injuries. Toxicological analysis showed the presence of cannabinoids and emergency medical treatment drugs. 4 CIRCUMSTANCES OF DEATH The deceased had moved to the UK some 5 years prior to his death. He was a hard- working, intelligent man who, up until late 2012, had been both physically and mentally fit and well. In around February 2013, the deceased's family and a close friend (with whom the deceased lived and worked) noticed a marked change in his mental health. He was exhibiting bizarre and erratic behaviour. The deceased was taken to see a private Psychiatrist who diagnosed Mr Lewandowski as suffering from acute paranoid psychosis. The Dr did not consider that the deceased was suffering from Schizophrenia and he explained his reasoning for this during the course of his evidence. The deceased was commenced on oral Olanzapine and was given a 2-week follow up appointment. The deceased failed to keep this and no further follow-up was organised. The Psychiatrist did not write to the GP/local NHS Mental Health team etc. following the consultation, nor did he see any reason to do so. It was the Psychiatrist’s evidence that the Practice Director had taken the decision not to correspond with patients’ GPs directly and that the CQC were aware of this practice. The deceased was reluctant to take medication and was for ail intent and purpose non- compliant. He did not believe that he was unwell. For a period, the deceased's friend was able to covertly administer Olanzapine and there was a clear correlation between being medicated and an improvement in the deceased's mental health. Unfortunately, due to a change in shift patterns the deceased's friend was unable to sustain this course of action and Mr Lewandowski’s mental health began to deteriorate again, due to ongoing non- compliance with his medication. The deceased's friend and sister both contacted the Psychiatrist (separately) to express their concerns about this and on each occasion were advised to take the deceased to the emergency room or his GP in the event of an acute exacerbation. The Dr did however alter the prescription (March 2013) from tablet form Olanzapine to dispersible, as he thought that the deceased's reluctance might have been due to the fact he found it difficult to take tablets. Between March 2013 and early July 2013, there appears to have been a period of status quo. However by mid-July changes were afoot in terms of the deceased’s mental health again. Consequently, several attempts were made to by the deceased's friend to get help for Mr Lewandowski, predominantly via the emergency services. There was evidence of police contact shortly before the deceased’s death (14"" ~ 15 July — the deceased had been lawfully arrest and detained in custody on suspicion of criminal offences), during which concerns were raised by the Custody Sergeant regarding the deceased’s mental health and wellbeing. As the custody time limit was due to expire, the deceased was granted technical bail but detained under S.136 of the Mental Health Act, pending the arrival of the Force Medical Examiner (FME - employed by MEDACS). This was accepted by the Force as, prima facie, unlawful as the deceased had not been ‘ina public place’. However it took a pragmatic view - that it was less stressful for the individual to remain detained than to be released and re-detained as soon as he stepped into a public area. This was based on understandable concern for the deceased's safety and welfare. Significant delay ensued in securing the attendance of the FME (no less than 7 hours after having been initially called to attend). This was put down to the pressure of work on that particular day however during the course of the evidence GMP acknowledged that the demands placed upon MEDACS by the Force had increased considerably and certainly above the scope initially envisaged under the terms of their contract. The deceased was however eventually assessed by the FME and deemed fit to be detained, interviewed, charged and released. On the morning of the 16" July, Mr Lewandowski attended his place of work and spoke to his manager. The manager formed the view that the deceased’s behaviour was odd and called an ambulance. He notified the deceased's friend of Mr Lewandowski’s whereabouts as he was aware that fact that he had reported him as ‘missing’ the day before. Paramedics assessed the deceased and formed the view that he had mental capacity. He was encouraged to attend hospital of his own volition; he declined. The Deceased returned to his flat and awoke his friend. Again, he was behaving strangely. The ambulance service was asked again to attend upon the deceased at his home address by his friend. They found accessing the property difficult and were made aware of the presence of a ‘marker’, suggesting a risk of violence. It subsequently transpired that the ‘marker’ in question related to the block of flats rather than an individual or particular property within the complex. Paramedics called for police attendance. Due to the demands being placed upon the police service at the material time, their request was deferred for no less than 8 hours. During this period, the ambulance service ‘stood down’ until such time as the police could allocate a patrol. The deceased's friend continued to try and get help for Mr Lewandowski by contacting the emergency services. He was not kept updated. Subsequent analysis of the sequence of events in relation to calls made to GMP Communications relating to this matter demonstrated ongoing series of errors including: - Incorrect recording of the deceased’s name - Not reverting to clarify the name once an Interpreter was available to assist (the Deceased’s first language was Polish) - Staff did not follow escalation and call grading protocols where there were clear and unequivocal triggers to do so - Unjustified decision-making and gaps in record keeping - Evidence of less than best practice. On the evening of the 16” July, after the close of business, Mr Lewindowski made his way onto the roof of his employer's building, disrobed to his underwear, ran to the end of the roof and ‘dived’ off. He suffered catastrophic head injuries, resulting in his death two days later. 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:- 1. The timeliness of GMP’s response, against a backdrop of lack of adherence to/use of the escalation and call grading protocols. 2. Lack of communication between GMP and MEDACS regarding the existence of their escalation protocol resulting in the delayed attendance of an FME. 3. The use of S.136 of the Mental Health Act due to lack of resources ~ albeit on logical, pragmatic grounds. 4. The psychiatric practice’s failure and reluctance to correspond with a patient’s GPs and/or other healthcare professionals following consultation, jeopardising continuity of care. Clinical decision-making by a non-medically qualified Practice Manager. The view of the physician - that responsibility for maintaining a patient’s safety and wellbeing within the community rests entirely with the family and/or patient rather than the clinician. ACTION SHOULD BE TAKEN _| YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by the 10" December 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 namely: The Deceased’s family Care Quality Commission North West Ambulance Service General Medical Council 1am 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 from. 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: 16” October 2014 Signed: a
2 responses 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.
GREATER MANCHESTER POLl CE Sir Peter Fahy Q.P.M., M.A. Chief Constable Mrs L. Hashmi cç5. Assistant Coroner i-’-’ Greater Manchester North Phoenix House Heywood 18 December2014 tNc cbNc RE: Mr Lukasz LEWANDOWSKI (deceased) Thank you for your report dated 1th5 October 2014. In accordance with the contents of your Regulation 28 Report in respect of Lukasz Lewandowski, I reply to the matters you have asked me to consider as follows. 1. The timeliness of GMP’s response, against a backdrop of lack of adherence to I use of the escalation and call grading protocols. The Operational Communications Branch (OCB) has undertaken a review of its Escalation Policy. The intention of this review, which is in its final stages, is to ensure the OCB works effectively with Divisions to enhance its ability to effectively identify areas of risk and then effectively manage the allocation of patrols to address that risk. In cases when it becomes apparent that resources are unavailable for allocation, the Escalation Policy will ensure the incident is brought to the attention ofthe appropriate Divisional supervisor. On this occasion, the Branch acknowledges the prevailing Policy was not adhered to and in response has issued individual management advice to each member of staff involved in this incident. The supervisors responsible for these members of staff have also received formal feedback. The Escalation Policy has been re-circulated with a message from the Branch senior leaders impressing the importance of accurate recording of information on force wide incident logs (FWINs). All staff have been advised that incident entries of ‘no free patrol’ are not acceptable and radio operators have been directed to ensure they record regular updates detailing the allocation and availability of resources, along with a rationale for their prioritisation. In addition the importance of maintaining more meaningful dialogue with Divisional supervision in orderto formulate effective patrol plans and resource prioritisation has been highlighted. Locationaddress: GMP Force Headquarters, Central Park, Northampton Road, ManchesterM40 5BP Postal address: GreaterManchesterPolice, OpenshawComplex, Lawton Street, Openshaw, ManchesterMl1 2NS Tel: 101 The Branch Commander has reiterated the importance of implementing this policy in his weekly Branch Orders and both he and the Superintendent responsible for Operations have conducted one to one meetings with individual supervisors to raise their awareness and consolidate their responsibilities for and ownership of detailed force wide incident entries. The Branch Commander has identified this is a critical area of our business and has extended quality assurance processes within Command and Control to now examine and report upon compliance with the Escalation Policy within the OCB. In relation to the reports reference to attention to detail, specifically, the incorrect recording of Mr Lewandowski’s name and the failure to revisit the accuracy of this detail once an interpreter had been contacted. This matter has been addressed firstly, with the individual call handler who has been spoken to by a member of the senior leadership team and secondly, the whole Branch, who have been reminded of the importance, when using interpreters of capitalising upon their expertise to verify details and confirm their accuracy. In this case the Branch acknowledges the advantages of more effective use of interpreters, which would have ensured the police national computer (PNC) was correctly updated and that any subsequent checks would then have identified Mr Lewandowski’s correct details. Again, his message has been circulated across the whole Branch emphasising the importance of recording details accurately and the dangers of making assumptions, specifically the incorrect assumption that Mr Lewandowski had been arrested for criminal damage which then lead to the Ambulance Service refusing to attend an address where there may have been a violent individual. 2 Lack of communication between GMP and MEDACs regarding the existence of their escalation protocol resulting in the delayed attendance of an FME During the Inquest MEDACs acknowledged the volume of their workload affected their attendance to Mr Lewandowski, which was delayed. As such, it is difficult to state whether or not activation of the Escalation Policy would have secured their attendance any sooner. The Custody Branch acknowledges and agrees that it is a concern that the custody staff were not aware of the MEDACs Escalation Policy, or that in all appropriate instances staff should escalate calls in order to secure medical care provision, in the most efficient manner to those who need it most. As a consequence of Mr Lewandowski’s Inquest, the Custody Branch has circulated the MEDACs Escalation Policy directly to all staff (via email) and also included it in its October 2014 Custody Branch Orders (news bulletin). 3 Use of Section 136 ofthe Mental Health Act due to the lack of resources, albeit on logical, pragmatic grounds Once it was established the investigation into Mr Lewandowski’s alleged criminal behaviour could not be concluded, the Custody Sergeant rightly caused Mr Lewandowski to be police bailed. Police bail is an appropriate outcome, when further investigative lines of enquiry are necessary and ordinarily this course of action ensures the detainees stay in custody is not prolonged unnecessarily. Location address: GMP Force Headquarters, Central Park, Northampton Road, ManchesterM40 5BP Postal address: GreaterManchesterPolice, OpenshawComplex, Lawton Street, Openshaw, ManchesterMl1 2NS Tel: 101 then decided to detain Mr Lewandowski under Section 136 of the Mental Health Act due to his concerns about Mr Lewandowski’s mental state. It was established and agreed during the Inquest that this method of detention was a pragmatic decision, made by in the best interests of Mr Lewandowski. The application of Section 136 Mental Health Act legislation in this manner is neither encouraged nor condoned by Custody Branch. Sir Peter Fahy Chief Constable Location address: GMP Force Headquarters, Central Park, Northampton Road, ManchesterM40 5BP Postal address: GreaterManchesterPolice, Openshaw Complex, Lawton Street, Openshaw, ManchesterMl1 2NS Tel: 101
Grecn Surgery Lgd. G reen 4 S U R G E RY 415Ii Manrhestcrgrcen-surgery.tom Medical & Dental Care www.greeu-surger.coni Manchester08.12.2014 Mrs. U Hashmi AssistantCoroner Greater ManchesterNorth HM Coroner’s Court The PhoenixCentre Church Street Heywood OL1O 1LR Dear Madam, Re: Mr. Lukasz Lewandowski (Deceased) Regulation 28 Report Responseto a reporton action to preventotherdeaths (Regulation 29 The Coroners(Investigations) Regulations — We write regardingthe matter in reference and furtherto the Regulation 28 Report to prevent future deaths pursuantto the investigation and inquest intothe death of Mr. Lukasz Lewandowski. We have now had the opportunity to carefully consideryour report and will seekto addressthe matters ofconcern which have been raised and which can be addressed by Green Surgery and will deal with those in the order in which they appear in the report. 1.The psychiatricpractice’sfailure and reluctanceto correspond with a patient’s GPs and/ or other healthcare professionals followingconsultation,jeopardisingcontinuityofcare: There is at present within thesurgery a policyto refer patients to other health professionals, where appropriate andjustified and bearing in mind the informed consent of any patient on such referrals. Bearing in mind the particularcircumstances and lessons from this case, a protocol is now being implemented specifically in relation to psychiatric practiceso that a clear risk assessment must be recorded on the patient’s notes and such risk assessmentto be acted upon and communicated to other relevant healthcare professionals. This assessmentwill be reviewed atappropriate intervals where concerns such as a lackofcompliance with medication are raised. In instances such asthe present case, it is now envisaged tofollow up any report ofcompliancefailure with an invitation to - an appointment beingmadeso asto discussthe impactoffailuretofollow medication aswell asto perform a re-assessment ofthe risks thatthe patient may presentto her/ himselfas a direct result ofthe non compliance. — This measure is to be implemented with immediate effect. 2.Clinical decision making bya non-qualified Practice Manager: — Registered in England and Wales No. 6751673 Grccn %urgcry Lid. G ree n 18-22 1osIey Strcci Manrhcsier FchOIGI 228 6I5 Manchcstergrccn-surgcry.toni Medical & Dental Care www.grccn.%urgcr.ro.n All decisions to refer patients for clinical purposes to another health professional are taken bythe medical practitioner under whose care the patient is. Itwill not be appropriate for the Practice Manager or any manager (unless clinicallytrained and significantly involved in the care ofthe patient in a clinical capacity) to form a view as to the appropriateness ofa referral to another healthcare professional. At present,the Practice Manager may be involved in facilitatingthe process of referral, butanysuch steps will only be taken as a complementaryaction to the assessment and subsequent referral made bythe treating clinician and is strictly limited to administrative and logistical support in makingsuch referral. With immediate effect, where such referral is made, the patients note must clearlyshowthe name and identifiers ofthe clinician makingthe referral and the extent of any action by a non-clinician mLlst be made clear in the notes. Responsibility for the patient’s treatment including referrals mustfully rest with the treatingclinician. 3.The view ofthe physician that responsibilityfor maintaining a patient’ssafety and well beingwithin the community rests — entirelywith thefamilyand/ or patient ratherthan the clinician: Green Surgeryseeksto provide a holistic approach to its patients’ treatment. With this in mind, it is accepted that it is imperative thatthe clinician and the practice are fully involved in efforts to keep patient’s safe and well within the community. This, it is agreed, means an ongoing engagement and wherever possible, a fact-finding exercise ofthe patients’ health support package and needs. In view ofthis, the referral system within the surgery is being improved to include specific “flag —raisingoccurrence” (e.g. failure to attend a follow up appointment, reports of medication non-compliance) additionally, the surgery will with immediate - effect encourage a more inclusive and participating approach from clinicians in the care oftheir patients. At present, literature and information is being prepared to clearly indicate the community links and resourcesthat can be accessed by patients and theirfamilies and howfarthe surgery can go in their assistance, thisto be given a place of prominence within the surgery. It is expected that such literature is to be ready and circulated within the surgery within the next three (3) months. Additionally, patients and their families currently have access to an out of hour’s emergency number and this practice is to continue. We hope thatthe above clarifications are ofassistance, however, please rest assured ofour continued assistance if need be. Yours sincerely, Green Surgery Ltd 18-22 Mosley Sireet ter s12 3AG 07519137072 ComplianceOfficer - Green SurgeryLimited Registered in England and Wales No. 6751673
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