Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0002, written 8 Jan 2015. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 8 Jan 2015 |
|---|---|
| Reference | 2015-0002 |
| Deceased | Eve Cullen |
| Coroner | Geraint Williams |
| Coroner area | Worcestershire |
| 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.
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: 1. Worcestershire Health & Care NHS Trust 2. 3. 1 | CORONER | am Geraint Urias Williams, Senior Coroner, for the coroner area of Worcestershire 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 19" August 20714 | commenced an investigation into the death of Eve Cullen then aged 52 years. The investigation concluded at the end of the inquest on 7” January 2015. The conclusion of the inquest was open the medical cause of death being unascertained 4 | CIRCUMSTANCES OF THE DEATH Mrs Cullen suffered from epileptic seizures following brain surgery in 2011 and had a ‘fluctuating peri ictal confusional state. In June and July 2014 she had been an in-patient at the Queen Elizabeth Hospital in Birmingham before being discharged home. . The psychiatrist at the Queen Elizabeth Hospital made a referral to the Redditch & Bromsgrove Community Mental Health Team for follow up but this was not actioned by the CMHT. On the 14" and 15” of July 2014 Mrs Cullen was seen by 2 different psychiatric nurses (one at Birmingham the other at Redditch), both of whom made urgent referrals to the Redditch & Bromsgrove CMHT. Mrs Cullen was offered an appointment to see the CMHT on the 24" of July 2014. On the 17” of July Mrs Cullen went missing from her family home whilst, apparantly, in a Per ictal confusional state and her body was later discovered in an alleyway on the 9” of August 2014. She had clearly been dead for some time. | 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 uniess action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. — (1) The failure to action the referral from the Queen Elizabeth Hospital (2) The failure to treat the 2 referrals on the 14" & 15" July 2014 as urgent (3) The lack of any uniform agreement as to what constitutes an ‘urgent’ referral | received evidence ro iii Clinical Lead, for the Redditch & Bromsgrove CMHT who confirmed that there was no evidence on the file that the I referral on file had been actioned at all. She confirmed that (as set out in the root cause analysis which has been prepared), there is no service wide definition of what might | | constitute an urgent referral (nor any agreed definition of such terms as ‘very urgent’, ‘immediate’, 'routine’) and further when referrals are made no suggested timeframe is recorded. She also told me that once the referral is received it is a matter for the psychiatrist as to ; when the patient is seen, even though the psychiatrist would not have had any contact with a new patient referred in this way. Although it is impossible to tell whether faster action may have changed the outcome in this case it seems that when 2 mental health professionals ask for an urgent referral but no action is proposed for some 8 days that this amounts to a lost opportunity to intervene and possible save the life of the patient | would ask the Trust to consider that terms such as ‘very urgent, ‘urgent’, ‘routine’ etc. should be defined with a view to there being a service wide understanding of what is | €xpeceted in terms of timely action upon referrals that are made ae ore aan ee ene nee ee 6 | 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. 7 | YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 5" March 2015 1, 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 eee a | have sent a copy of my report to the Chief Coroner and to the following Interested | 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. ; bo G U Williams 8th day of January 2015 H M Senior Coroner ies)
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.
VWoQ\S AE Worcestershire Health and Care NHS) NHS Trust Chief Executive’s Office Worcestershire Health and Care NHS Trust lsaac Maddox House Shrub Hill Road Worcester WR4 9RW Tel: 01905 733674 www.hacw.nhs.uk Your Ret as Our Ref: a Date: 3 March 2015 Mr G U Williams HM Senior Coroner for the County of Worcestershire The Court Office Bewdley Road STOURPORT ON SEVERN Worcestershire DY13 8XE Dear Mr Williams Re: the late Eve Cullen Regulation 28: Report to Prevent Future Deaths | write further to your letter dated 8 January 2015 in accordance with Regulation 28 of the Coroner's Rules in respect of the late Eve Cullen. | confirm that the Trust conducted a serious review of this incident and acknowledge that there have been differences in how urgent referrals have been dealt with by the Trust in different parts of the county. The Trust is commissioned to provide mental health services in Worcestershire by three difference clinical commissioning groups; namely Redditch & Bromsgrove CCG, Wyre Forest CCG and South Worcestershire CCG. In terms of South Worcestershire, there are very clear protocols agreed with the Clinical Commissioning Group identifying the timescales for referrals made by general practitioners and other professionals and having a standardised system for processing such referrals. Unfortunately, it has not to date been the case that the same process applies in respect of the other areas in which the Trust provides services in Worcestershire, however we are working with the North CCG’s to address this, as it is our ambition to introduce a standardised system across the County. The Trust is working towards performance measures for all categories of referrals and will incorporate into a policy, which will distinguish between urgent and routine referrals with defined timescales for contact. Whilst there had been discussions in respect of this issue for some time, as a result of you bringing this matter to my attention, | confirm that | have taken action to improve processes in Redditch and Bromsgrove in respect of the timescales in which urgent referrals are dealt with. | confirm that since receiving your correspondence the Trust has written to all general practitioners in Redditch & Bromsgrove on 4 February 2015 identifying a protocol for the referral of mental health patients and the timescales in which they can be seen. This clarifies that referrals marked urgent should be triaged within 24 hours. The triage process may involve a discussion with the referrer, a discussion with the individual and/or a face to face assessment. The referral will be received by the CMHT duty worker, who will agree with the referrer a timescale for response. All referrals agreed as requiring an urgent response will be seen for a face to face assessment within 24 hours. The CMHT duty worker will agree with the referrer what actions the CMHT will take and how any outcomes will be reported. The CMHT will contact the patient to discuss the referral and make arrangements for the assessment to be completed Whilst this process has recently been implemented, data is being gathered to enable a review to assess effectiveness and to identify any issues. A similar process is being implemented in Wyre Forest. When the assessments of 14 and 15 July were referred to the CMHT these were noted as requiring assessment within a week; unfortunately this did not happen within that timescale due to a lack of clarity about timescales. Whilst | recognise, that tragically, these changes have come too late for Mrs Cullen, | confirm that | will be writing ‘cc outline the information provided to yourself and to offer my apology for the confusion in respect of the referral to the community mental health team in respect of his wife’s care. One issue that | do need to raise with you is in respect of the referral from the Queen Elizabeth Hospital dated 4 July 2014 which you did not believe had been actioned by the community mental health team. Having reviewed this matter, it was clarified that the referral dated 4 July 2014 was received by the community mental health team on 11 July 2014. Discussions with the Queen Elizabeth RAID (rapid assessment interface, discharge) confirmed that at the point of the referral urgent follow-up was not indicated, as a result the referral was due to be reviewed by the weekly multidisciplinary team meeting. Clearly, by 14 July 2014 the situation had changed and Mrs Cullen’s presentation appeared to be more worrying and this was where there was a further opportunity for a fuller assessment, it was due to a lack of clarification about timescales that the assessment unfortunately did not occur prior to Mrs Cullen leaving home on 17 July. | recognise that the Trust did not ensure that you had all the appropriate evidence available at the inquest in respect of the initial involvement of the CMHT. As you are aware the Trust has recently recruited a new Company Secretary who will be leading on inquests, and will be seeking to ensure that you are provided with appropriate information to enable you to conduct a full inquiry into the circumstances of deaths. | am confident that the new system adopted in Redditch and Bromsgrove will bring into line the processes that currently operate in the south of the county and appear to operate in a smooth manner. | would like to thank you for drawing this matter to my attention and hope that you feel the Trust has addressed the issue appropriately. | confirm that | will write personally to IEEE explaining what action has been taken. Yours sincerely Sarah Dugan Chief Executive
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