Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0485, written 10 Nov 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 10 Nov 2014 |
|---|---|
| Reference | 2014-0485 |
| Deceased | Roseanne Cooke |
| Coroner | Joanne Kearsley |
| Coroner area | Manchester South |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Boroughs Partnership NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
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REGULATION 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 5 Boroughs Partnership NHS Foundation Trust 1 | CORONER | am Joanne Kearsley, Area Coroner, for the coroner area of South Manchester 2 | 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 3 | INVESTIGATION and INQUEST On 6 May 2014 | commenced an investigation into the death of Roseanne Cooke — date of birth 20.05.1958. The investigation concluded on the 27" October and the conclusion was one that the deceased had taken her own life. The medical cause of death was recorded as 1a) Hanging 4 | CIRCUMSTANCES OF THE DEATH | heard evidence that the deceased had, over a relatively short period of time, had a marked deterioration in her mental health — a prominent feature of which was suicidal thoughts. She had been an inpatient on the Sheridan Ward in January 2014 until her discharge on the 7" February 2014. On the 26" February she then re-presented having taken an overdose and was then transferred to the Grasemere Unit at Whiston Hospital due to a shortage of beds. She remained an inpatient and was transferred back to the Sheridan Ward on the 9"" April. A week later on the 17™ April 2014 she was discharged home under the care of the Home Treatment and Recovery Teams. On the 1** May 2014 the deceased was found having taken her own life at her Mother’s home. 5 | 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. — - It was clear from the evidence that the deceased required psychological input. The Inquest heard evidence that whilst she was an inpatient on the Grasmere Unit there was no inpatient psychological input available due to maternity leave which had not been covered. -___ There was confusion in the evidence as to whether, whilst an inpatient on Grasmere, a referral had been made to outpatient psychological services (i.e. the Recovery Team services). This resulted in a referral being made by her Care Co-ordinator on the 24" April when she had been already been discharged home. This confusion meant that there was either a delay in any referral being made or at best a duplication of her referral. - Onthe 17" April there was a meeting which ultimately led to the discharge of the deceased from hospital. The Care Co-Coordinator had already expressed that she would not be available due to annual leave but had left details of her colleague who would attend if this was a discharge planning meeting. No-one from the Recovery Team attended this meeting. They were the prime carers for the deceased on her discharge and had the role of Care Co-ordinator. - On the 28" April, the deceased’s family contacted the Home Treatment Team out of hours numbers available to them as they had concerns about the deceased being in the house on her own the following day as she was having suicidal thoughts. Their understanding of the request was that someone from the Recovery Team would visit her the following day. The message passed to the Recovery Team was simply to make contact with the deceased, which was done over the phone. The extent of the concerns raised by the family was not communicated to the Recovery Team. | ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you 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 by 5 January 2015. I, 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 co the Chief Coroner and to the following Interested Persons namely | have also sent it to Greater Manchester Police who may find it useful or of interest. | 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. ate: 10 November 2014 arsjey, HM Area Coroner Manchester South
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.
Your Ref: Our Ref: 30 December 2014 PRIVATE AND CONFIDENTIAL Miss J Kearsely Area Coroner H M Coroner Manchester (South) HM Coroners Court 1 Mount Tabor Street Stockport SK1 3AG Dear Miss Kearsley 5 Boroughs Partnership NHS) NHS Foundation Trust Hollins Park Hospital Winwick Warrington Cheshire WA2 8WA Fax: Ene: Re: Mrs Roseanne Cooke (Deceased) Thank you for letter dated 10 November 2014 with regards to your findings into the death of Mrs Rosanne Cooke and the directions given under Regulations 28 and 29 of the Coroner's (Investigations) Regulations 2013. The Trust takes the matters described within the letter extremely seriously and hopes this response addresses the concerns you have raised. In addition | hope | have demonstrated to your satisfaction the learning within the Trust as a result of your correspondence. Taking your points inturn | can confirm the following actions have been undertaken by the Trust: L. Psychological Input —- Grasmere Unit TruSt'Headguarters, Holi Chief Executive: Mr. Simon J. Barber Chairman: Mr. Bernard Pilkington ins Park House, Hollins Lane, Winwick, Warrington, WA2 8WA Mini Com Number 01925 664094 The Trust has looked into the concerns you have raised regarding psychological ollowing has been input whilst Mrs Cooke was a patient on Grasmere Unit and the fi established. The Grasmere Unit Psychologist was on maternity leave, from 1 October 2013 — 1 September 2014, Mrs Cooke was admitted on 7 March 2014. Psychology cover was provided during the period of maternity leave by the Psychological Therapy staff from Knowsley Recovery Team who attended ward rounds and provided psychological assessment/interventions as requested by Grasmere Unit. Unfortunately there is no record of Grasmere Unit staff referring Mrs Cooke, despite the identified need for psychological input. An action plan has been produced and is attached for your information. However | have taken the opportunity to summarise the actions below. The Trust operates a process for services to plan for extended leave such as maternity leave, however | recognise, in this instance, this did not work as well as it should. | would like to assure you that additional steps will be added to the process to ensure actions and those responsible are more formally identified. These steps are detailed within the attached action plan, along with action owners and dates for completion, and include: e Support from the Professional Lead for Psychology, who will review Psychology provision across the Trust and advise as to the options available for cross cover Psychology arrangements. Production of an extended leave plan that will have clear deadlines and ensure alternatives are identified at least four weeks prior to commencement of the planned leave. The Business Manager will ensure Grasmere Unit staff are instructed to provide more detailed entries into the electronic record system relating to psychological input discussions. This will include their immediate action(s) in relation to the patient. The Leadership Team for Grasmere Unit will commission an audit of the psychology referral documentation to ensure it identifies the type, level and urgency of referral. Il. Referral Process for Psychological Services It is evident that a delay occurred in processing Mrs Cooke’s referral to Warrington Recovery Team’s Psychology Service. | would like to offer my unreserved apologies to the family of Mrs Cooke for this delay which was a result of the Care Co-ordinator failing to submit a referral to Warrington Psychological Therapies (Warrington Recovery Team) in a timely manner. Chief Executive: Mr. Simon J. Barber Chairman: Mr. Bernard Pilkington Trust Headquarters, Hollins Park House, Hollins Lane, Winwick, Warrington, WA2 8WA Mini Com Number 01925 664094 St NBO, & EGY s é In response to this the Borough’s Leadership Team has implemented a plan to identify reasons for this failure via an audit of internal referrals to Psychological Therapies by Warrington Recovery Team. Findings from the audit will be developed into recommendations referral process. for improving the The failure to refer in a timely manner will be addressed with the Care Co-ordinator via Trust Management process and Clinical Supervision. lll. Discharge Planning Meetings The Trust operates a standard in relation to Discharge Planning Meetings which reflects the Care Programme Approach (CPA) principles. This includes a requirement for practitioners to ensure a safe, effective transition for patients. | would like to take this opportunity to advise you of Trust activity to implement use of the Safer Mental Health Checklist, developed by the National Patient Safety Agency (NPSA). This checklist ensures that the activity in relation to a patient's transfer from one team to another is planned and monitored. The checklist also includes a review of the Risk Management Plan prior to any change in service delivery and a review of CPA status between transfer and receiving teams. It is evident that Warrington Recovery Team (as the receiving team) failed to send any representation to the Multi-Disciplinary Team MDT meeting and this is an oversight on our part. In order to address this, the Warrington Recovery Team Manager will ensure annual leave handover forms are completed. These will detail actions pertaining to individual service users, and also which staff member within the Team will ensure these are completed in the absence of the Care Co-ordinator. These forms will be referenced at existing weekly Recovery Team meetings. The manager will ensure annual leave handover forms are discussed within the Team Meeting prior to any planned leave. This action will address the potential of such an oversight recurring and will also ensure that actions are known by all team members and recorded. IV. Communication between Teams The Trust operates an electronic patient record which ensures that activity in one team can be accessed by other Trust teams supporting the same patient. Informatio ing to contact from Mrs Cooke’s family was recorded and detailed concerns and request for a home visit to his wife for the next day. Having reviewed Mrs Cooke’s electronic record the following day, the Care Co-ordinator contacted Mrs Cooke to discuss. During this contact, Mrs Cooke Chief Executive: Mr. Simon J. Barber Chairman: Mr. Bernard Pilkington Trust Headquarters, Hollins Park House, Hollins Lane, Winwick, Warrington, WA2 8WA Mini Com Number 01925 664094 JE ABO, Raa = ke “4 s is pe® described feeling much better, and was out at the time of the call, dealing with banking affairs and it was agreed to keep to the scheduled appointment for the next day. The Care Co-ordinator was assured by her conversation with Mrs Cooke and advised that should Mrs Cooke’s feelings change in any way, then she was to make contact with her Care Co-ordinator. In conclusion | would again like to offer my apologies to the family of Mrs Cooke for the failings identified. | trust this letter and attached action plan addresses the concerns raised. If | can be of any further assistance or you require further information about the steps we have taken please do not hesitate to contact me. Yaurs sincerely Director of People and Integrated Governance Chief Executive: Mr. Simon J. Barber Chairman: Mr. Bernard Pilkington Trust Headquarters, Hollins Park House, Hollins Lane, Winwick, Warrington, WA2 8WA Mini Com Number 01925 664094 St ABOG 2 Con 5 2 isagx®
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