Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0527, written 5 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 | 5 Dec 2014 |
|---|---|
| Reference | 2014-0527 |
| Deceased | Paul Hyde |
| Coroner | Veronica Hamilton-Deeley |
| Coroner area | Brighton & Hove |
| 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.
VERONICA HAMILTON-DEELEY, LL.B. Her Majesty’s Senior Coroner for the City of Brighton & Hove Assistant Coroners CATHARINE PALMER LL.B (HONS) MICHAEL KEEN THE CORONER’S OFFICE WOODVALE, LEWES ROAD BRIGHTON BN2 3B BE YAS é i Telephone: Brighton (01273) 292046 Fax: Brighton (01273) 292047 KAREN HENDERSON, BSC,BM,MRCPI,FRCA GILVA D.J.TISSHAW, BA(LAW)HONS CORONERS SOCIETY OF ENGLAND AND WALES ANNEX A REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: . Chief Executive, Sussex Partnership Trust 1 2. BE — Chair Community Governance 3. Service Director, Brighton & Hove City Council CORONER 1am Veronica HAMILTON-DEELEY, Senior Coroner, for the City of Brighton and Hove 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. INVESTIGATION and INQUEST On 4" August 2014 | commenced an investigation into the death of Paul Leslie HYDE. The investigation concluded at the end of the inquest on 12" November 2014.The conclusion of the inquest was MISADVENTURE CIRCUMSTANCES OF THE DEATH See Record of Inquest 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) On the 14" April 2014, GP Dr. Peter Deviin having anxieties expressed to him by one of the Community Mental Health Workers concerning Paul Hyde's deteriorating condition, sought advice from the Assessment and Treatment Team of the Community Mental Health Services. He spoke to Graham Walton who advised him that he should refer Mr. Hyde back to ATS (Assessment and Treatment Service). He therefore wrote a letter on the 15” July, 2014 and this VERONICA HAMILTON-DEELEY, LL.B. THE CORONER’S OFFICE Her Majesty’s Senior Coroner WOODVALE, LEWES ROAD for the City of Brighton & Hove BRIGHTON BN2 3QB Telephone: Brighton (01273) 292046 Fax: Brighton (01273) 292047 Assistant Coroners . CATHARINE PALMER LL.B (HONS) MICHAEL KEEN KAREN HENDERSON, BSC,BM,MRCPI,FRCA GILVA D.J.TISSHAW, BA(LAW)HONS was sent so that it arrived on the same day, expressing his anxiety. The request was for Mr. Hyde to see a Psychiatrist to carry out a medication review.. It is clear that this Medication Review needs to be carried out by the Psychiatrist in a face-to-face review with the patient. The referral was not appropriately addressed until some 14 days in to the 28-day period within which the patient is required either to have been seen by ATS or the Psychiatrist or the GP. It was decided, though very poorly documented that the Psychiatrist should phone the GP to see whether, after discussion, it was possible for the GP to prescribe a new medication for Mr. Hyde. (2 ~ YL It should have been obvious from the start that this was not a direction for this referral to take. There seems to be no facility for the Psychiatrist to be involved in the assessment procedure and indicate a course him or herself. There should be. In any event, no contact was made with the GP and there is apparently no follow up system so no one seems to have picked up that not only was Mr. Hyde not seen within the 28-days of referral, but in fact that he was not seen at all i.e. he was lost to follow up. (4) From the point of view of Mr. Hyde, the re-referral system was not fit for purpose. In the event, Mr. Hyde took an overdose of the medication which had been stopped, although he still had some tablets, and the very sedatory effect that he had complained about kicked in, resulting in his death. 6 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. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report (5" December 2014), namely by 24" February 2015. |, Veronica Hamilton-Deeley, 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. 8 COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the following Interested Persons 1. Clinical Commissioning Group . (Mother) 3. NEE (Father) 4. Secretary of State for Health, Department of Health §. Sir David Nicholson/Simon Stevens — Chief Executive NHS England 6. National Patient Safety Agency THE CORONER’S OFFICE WOODVALE, LEWES ROAD BRIGHTON BN2 3QB + VERONICA HAMILTON-DEELEY, LL.B. Her Majesty’s Senior Coroner for the City of Brighton & Hove Assistant Coroners CATHARINE PALMER LL.B (HONS) MICHAEL KEEN KAREN HENDERSON, BSC,BM,MRCPI,FRCA GILVA D.J.TISSHAW, BA(LA W)HONS Telephone: Brighton (01273) 292046 Fax: Brighton (01273) 292047 | 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. 9 Date: 5" December 2014 SIGNED BY: Veronica HAMILTON-DEELEY a Senior Coroner Brighton and Hove
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.
A teaching trust of Brighton Sussex Pa rtnership and Sussex Medical School NHS Foundation Trust Swandean Arundel Road 10 February 2015 Worthing . : : ] West Sussex Miss Veronica Hamilton-Deeley LLB j re BN13 3EP Her Majesty's Senior Coroner for the City of Brighton & Hove . The Coroner's Office Woodvale Lewes Road Brighton BN2 3QB Dear Miss Hamilton-Deeley Re: The late Paul Leslie Hyde Thank you for your letter of 2 December 2014, your report written pursuant to the Coroners & Justice Act 2009 and regulation 28 of the Coroners (Investigations) Regulations 2013, and for drawing your concerns to my attention. | was very sorry to read your concerns in relation to the sad death of Mr Hyde. Firstly, | wish to offer our condolences to Mr Hyde's family. amar ae: myself have taken the matters you have raised extremely Seriously, and seek to reassure you that work has been undertaken, and is on-going, to improve practice in Sussex Partnership NHS Foundation Trust. This letter is a joint response from all recipients. The letter was directed to the City Council and although mental health services in Brighton and Hove are integrated with the Council there was no specific role identified for Adult Social Care & Health in Mr Hyde’s care. Your concerns relate to the Assessment and Treatment Service (ATS) clinical triage service. West Assessment and Treatment Service Team Manager confirmed that ere was a four day delay in the triage administrators sending Mr Hyde's GP re referral to the West Hove Assessment and Treatment Service. Service Director for Brighton & Hove has confirmed that he is in discussions with the CCG and there is in place a joint Performance Improvement Plan in relation to the 4 Week Wait for routine referrals into the Assessment & Treatment Service. Actions include, a review of the administration triage processes to address triage waiting times. This recognised the need for an additional administrator in Triage and | am pleased to say recruitment to this post has been completed. A further action was a review of the triage function/process to include increased involvement from Consultant Psychiatrists and additional members of ATS. All clinical triage meetings have a Consultant Psychiatrist, lead nurse, and administrator present. Following Mr Hyde’s noves Associate Specialist has been invited to attend the triage meetings on a regular basis. The use of the Breach Tool has been extended and the system is now more robust. Medical Personal Assistants now complete this for all referrals, regardless of the triage decision. Team leads have oversight of the tool and it is a ‘live’ record of all pending contacts, whether by telephone or face to face with service users. All actions / outcomes from the clinical triage meetings are now recorded on the Breach Tool and these are closely monitored. The Breach Tool guidance has been reviewed and staff have received clear instruction on how to use the tool. Chief Executive: Colm Donaghy Chair: John BaconCB Head office: Sussex Partnership NHS Foundation Trust, Swandean, Arundel Road, Worthing, West Sussex, BN13 3EP www.sussexpartnership.nhs.uk In his evidence to you I sic that an appointment with himself would have been appropriate for Mr Hyde. You were understandably very concerned about this, as | was, and our shared concerns have been thoroughly addressed within the Trust. To reduce the likelihood of a similar occurrence in the future, the following improvements to the service have taken place in order to ensure all triage decisions are appropriate and clinically led: A meeting with the CCG Clinical Lead, Sussex Partnership Clinical Lead for Community Services and Sussex Partnership Managers was held to review the ATS data to ensure all actions relating to referral management are clinically led and appropriate. In addition, Service Manager for the Assessment & Treatment Service for Brighton & Hove has agreed to undertake a quarterly audit of the triage outcome decisions, with an independent senior clinician, to ensure our triage decisions are appropriate. We continue to discuss and review our performance against key performance indicators with commissioners ona monthly basis and maintain an updated action plan to ensure this remains a continual focus for quality improvement. We are always striving to improve the interface between primary care and secondary mental health services. In order to improve relationships between GPs and Consultant Psychiatrists, GPs have been allocated named Consultant Psychiatrists. Meetings between the psychiatrists and GPs have been arranged. [Eis leading on this to ensure both GPs and psychiatrists are clear on their roles and the expectations of referrals. Work is on- going to ensure there is a joined-up approach for our service users and their families and there is continual learning and improvement. Mr Hyde’s experience has been shared (anonymously) with staff to drive home the lessons to be learned. In addition, to ensure widespread learning, feedback from the case has been given t Director of Nursing Standards and Safety. This has guaranteed the issues are hign profile and education and understanding is widespread. Furthermore, in order to educate all staff, lessons learned from Mr Hyde’s experience have been included (anonymously) in the Trust’s Quarterly Quality & Patient Safety Report. As you highlighted, we will never know if the outcome would have been different if Mr Hyde had been seen by | prior to his sad death, however, we can reassure you that systems have been reviewed and improved and staff have carefully reflected on what happened. Thank you once again for raising your concerns. | hope the actions outlined in this response demonstrate how important these issues are to the Trust, and how seriously we have taken the matters highlighted at Mr Hyde’s inquest. | feel sure that future service users will benefit from the lessons we have all learned following Mr Hyde’s death and | hope Mr Hyde’s family can take some comfort in knowing this. Yours sincerely olm Donaghy Chief Executive
See every Prevention of Future Deaths report matching Hospital Death (Clinical Procedures and medical management) related deaths, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.