Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0523, written 2 Dec 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 2 Dec 2014 |
|---|---|
| Reference | 2014-0523 |
| Deceased | Anthony Williams |
| Coroner | John Gittins |
| Coroner area | North Wales (East & Central) |
| 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 (1) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: BCUHB, Ysbyty Gwynedd, Penrhosgarnedd, Bangor, Gwynedd LL57 2PW 1 CORONER lam JOHN ADRIAN GITTINS, senior coroner, for the coroner area of North Wales (East and Central)] 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 the 13" of February 2014 | commenced an investigation into the death of Anthony Gwyn Williams, (DOB 20.05.1972, DOD 09.02.2014). The investigation concluded at the end of the inquest on the 27" of November 2014 and I recorded a narrative conclusion in the following terms :- On the 9"" February 2014 Anthony Gwyn Williams was showing signs of a decline in his mental health which were typical of the condition for which he had been receiving treatment from the Mental Health Services. He expressed a wish to attend hospital for a further assessment and treatment but due to his condition he was unwilling to access such medical intervention through the recognised pathway of attendance at the Accident and Emergency Department. As a result he went to a location where he would not be easily found within Pentwmpath Woods and with the use of a ligature he took his own life whilst the balance of his mind was disturbed. 4 | CIRCUMSTANCES OF THE DEATH The Circumstances of the death are as detailed in the above narrative conclusion. 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. Although a memorandum has been issued to staff advising that there may be times when it is appropriate to deviate from the recognised pathway of psychiatric assessment within the Emergency Department, no clear training or guidance has been given to staff as to what may constitute such “exceptional cases”. 2. There needs to be access to the medical records of existing patients at all times including evenings and weekends especially regarding a patient's Care and Treatment Plan. 3. There should be greater engagement with family and carers of patients (with patient consent) to ensure that they are aware of the contents of patient's Care and Treatment Plan especially with regard to the options which may exist in times of crisis. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe your organisations 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 27" 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 copy of my report to the Chief Coroner and to the following Interested Person -( (Wife of the deceased) lam 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. [DATE] 2™ December 2014. [SIGNED BY CORONER] Te cere
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.
ZR IG Bwrdd techyd Prifysgol Ysbyt - y Gwynedd, Penrhosgarnedd, Bangor, Oe CYMRU Betsi Cadwaladr Gwynedd, LL57 2PW O- Wy IIS | University Health Board ane PRIVATE & CONFIDENTIAL Ein cyf/Our ref: [I Mr John Gittins ; . HM Coroner's Office Eich cyt / Your ref: County Hall Rhif Ysbyty / Hospital Number: Wynnstay Road Rhif GIG / NHS Number: Ruthin gS. LL15 1YN Gofynnwch am/ Ask for: Ffacs / Fax: E-bost / Email: ConcernsTeam.bcu@wales.nhs.uk Dyddiad / Date: 30" January 2015 Dear Mr Gittins Response to your Regulation 28 Report following the Inquest into the death of Mr Anthony Gwyn Williams | write further to your Regulation 28 Report following your investigation into the circumstances of Mr Williams’ death. Thank you for providing the Health Board with the opportunity to advise you of the steps we are taking to improve our Mental Health Services and prevent future deaths. During the course of your Inquest | acknowledge some of the evidence produced revealed matters that gave rise to concern as follows: 1. Although a memorandum from the Chief of Staff was circulated to all Medical, Inpatient and Psychiatric Liaison staff on 8 September 2014, it did not provide these staff groups with any guidance as to what constitutes ‘exceptional cases’ in terms of where out of hours psychiatric assessments should take place. | am pleased to report that since this incident, we now have a larger number of psychiatric nurses present on the Heddfan Adult Unit out of hours and in similar situations in the future, socially anxious patients such as Mr Williams could be assessed at the Unit and would not need to await psychiatric assessment at the Emergency Department. Notwithstanding this, our Business Manager for Safety & Regulation will fully discuss this matter at the next Operational Management meeting to ensure full understanding and compliance across the Mental Health & Learning Disabilities Division. 2. In respect of medical and nursing staff having access to patients’ records, such as Care and Treatment Plans at all times, | can advise you that the adoption of an electronic case record is currently being explored as part of the Community Care Information System national procurement. The Health Board will determine its preferred approach to developing electronic records by March 2015. 3. In relation to greater engagement with the families and carers of mental health patients to ensure their awareness of the contents of patients’ Care and Treatment Plans, as a Cyfeiriad Gohebiaeth ar gyfer y Cadeirydd a'r Prif Weithredwr / Correspondence address for Chairman and Chief Executive: Swyddfa'r Gweithredwyr / Executives’ Office, Ysbyty Gwynedd, Penrhosgarnedd Bangor, Gwynedd LL57 2PW Gwefan: www.pbe.cymru.nhs.uk / Web: www.bcu.wales.nhs.uk general principal if a patient has capacity to make decisions about whether family members or carers are involved in a patient's care planning and care, then services are obliged to respect that decision unless there is an overriding public interest, which merits disclosure of information. Where the involvement of family and carer's is accepted by the patient, the sharing of the Care and Treatment Plan would be appropriate. | am assured that all patients are provided with a copy of their Care and Treatment Plans. If a patient lacks capacity to make decisions about the involvement of family or carers there should follow a best interest decision. | would suspect in the majority of cases the involvement of family and carers would be in a person’s best interest. Please do not hesitate to contact me if | can be of further assistance in this matter. Chief Execitive cc Chief of Staff, Mental Health and Learning Disabilities CPG HE Complaint Lead
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