Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0019, written 21 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 | 21 Jan 2015 |
|---|---|
| Reference | 2015-0019 |
| Deceased | Sian Armstrong |
| Coroner | Maria Voisin |
| Coroner area | Avon |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths · Child Death (from 2015) |
| Organisation named | North Bristol NHS Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
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.
North Bristol NHS Trust Trust Headquarters Southmead Hospital Southmead Road Westbury-on-Trym Bristol BS10 5NB Tel: 42 March 2015 Website: http:/Awww.nbt.nhs.uk Coroners Court The Court House Old Weston Road Flax Bourton BS48 1UL Dear Ms Voisin Re: Sian Armstrong Thank you for your letter dated 22 January 2015, in which you have set out your concerns under Schedule 5 of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroner (Investigations) Regulations 2013. | have reviewed your concerns with our Community Children’s Health Partnership (CCHP) and can confirm the following actions/plans in place for future management of young people who require therapy. e Firstly, | would confirm that appropriate Psychological therapy is available through the CAMHS services; however Sian refused treatment from CAMHS service. Sian was informed about other services available to her for example from the voluntary sector and later made an informed choice to self-refer to Off the Record for counselling. e We have developed a new protocol to assist CAMHS clinicians who are faced with young people do not want to engage. (attached) e Whilst we have to be cognisant of young people's consent and competency in relation to involving parents and carers, we will invite parents to contact CAMHS if they have ongoing and or additional concerns. We will listen to them and consider their concerns. This principle will be introduced into all correspondence with families / carers and young people from 1 April 2015. e Bristol and South Gloucestershire Clinical Commissioning Groups (CCG) directly commission Tier 2 services from Off the Record. We are working with our two CCG’s, to involve Off the Record in our CAMHS intake meetings Peter Rilett A University of Bristol Teaching Trust Andrea Young Chairman A University of the West of England Teaching Trust Chief Executive where we triage and assess all referrals for young people. This collaborative new model of working aims to provide appropriate resource for mental health problems, more choice for young people and ensure timely access to the right service to meet the needs of young people. Work has begun to finalise governance arrangements for cross organisational working. Agreement was reached in February 2015 that Off the Record staff could attend CAMHS locality intake meetings. e For young people who are hard to engage we have been working with the Bristol Clinical Commissioning Group (CCG) to develop a Crisis intervention team model. A Project Lead has been appointed by Bristol CCG and is currently scoping local services in order to recommend a best model of practice. This will improve the response to young people who self-harm. The crisis intervention team is currently being planned for implementation in June 2015. An assertive outreach project is planned to deliver services to hard to reach young people for example those with forensic difficulties and substance misuse. The implementation of this will take place following the re procurement of the Community Children’s Health Partnership in 2017. | would like to reassure you that the Trust is continually working to improve its services at the present time and for patients in the future. Yours sincerely Andrea Young Chief Executive Peter Rilett A University of Bristol Teaching Trust Andrea Young Chairman A University of the West of England Teaching Trust Chief Executive f gpoddns 5 | ajqejieae: Suipsesas uoeWUojul ||2 sAey siase2'/ sjussed: og ase) Aleuitid OF yIeq pa} UOMeULOsUt IY aoejd-uiynd ued Ayajes } —_ gd.01 eq uajau'pue SHIAIYD. 03 Pssops ese) f Ge Aes. « | power HO « + spaou suossad unoA Sunjaaw jo sAem.JayIO weapisuod qsnuu.ueDiuls yseq é Suig0u0a Bujosuo-aney 32 $1 eUOI.0] Suased / syuased payAUINOADARH - &}uN0Ie Ul UdY2} S49429 /sjuased JO Susa0U09 PUR SMAIA BY} B12 MOH « é dupjew uoisisap suosiad SunoAd uly juapiaa siased / squaied aye éssaieo/ sjuaied aue panjoaul / padedua MoH « gaspaymouy i 4O uOlssilused jejuased JO) paau ay} yNoYjM SuiprenSayes osayy aay « ‘Quawjeds7 jed1paus UMO J3Y JO'sIy GO} JUsSUOD 0} 8142. pue Ua}adwos souyapINg sasesy :49ptsuoo qsnu erat yea / ND uosusd Bunod ayy si sweaA QT sepun fs] 6 | eayeudoidde 3g jUaWaAlOAU! Anuade IN PINOMA. + ON:/ S@A é SUJaIUOS é juasuod pawuojul iN : uo paseg uolsioap suosiad SunoA.ayy s}: + ler Japisuod ysnud ueloiul|9 Yyseg j asnjal 0} SanuyjUo? UOSIdd BUNO,A ON / S8A é Ayoedes aaey UOSsed SunoA 3y} S80q ON / SPA é PY Use3H jeQUayy 34} Japun ayqeulerap pesapisuo0s uosiad 3unoA au} s} asnjas 0} sanuuod uosuad BUNOA f1 West SHINY) SAQeWa}]e Jap!su0>, URIIUND puZ /Wwawyjeeas sasnjas , uosaad duno, ueiuy> aaneusye *) | Adeseup sasnyad jal ue “ aoe genome: J0.JNYGIOY UEID|UNP 4s. YUM: diysUOHelaL HOP PIsuoD | pulj JOU sd0p, UOsiag BUND, Adesay} ul sasesua uosiad Buno, } Uy BBeBus:0j ajqe pue Adesayy jen1ZojoyoAsd wou Bun] yauag se passasse uosisg BUNOA SNL SHN | O1SUg YON
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: 4. North Bristol NHS Trust CORONER | am Maria Voisin, Senior Coroner, for the area of Avon CORONER'S LEGAL POWERS I 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 11" June 2014 | commenced an investigation into the death of Sian Leigh ARMSTRONG, Aged 17. The investigation concluded at the end of the inquest on 44" January 2015. The conclusion of the inquest was as follows: Medical Cause of Death 1a) Hanging Conclusion Sian Armstrong had a history of depression, she was under the care of the mental health service and on the balance of probability took her own life. al CIRCUMSTANCES OF THE DEATH Sian had a history of depression. In March 2014 she made an attempt on her life by way of an overdose. Following this she had been seen by the Mental Health Team. Sian was assessed as needing to receive CBT but from the time of the assessment in March 2014 until her death in June 2014 she had not received CBT CORONER'S CONCERNS Serre eee 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. There was a delay in Sian receiving CBT which she was assessed as requiring. 2. At the inquest | indicated that | would ask North Bristol NHS Trust for reassurance that steps will be taken to ensure that this therapy is available to children who are assessed as needing it in a timely manner 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 18 March 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 Persons — the family - and to the LOCAL SAFEGUARDING BOARD. | 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. 21.1.15 M. E. as
See every Prevention of Future Deaths report matching North Bristol NHS Trust, 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.