Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0032, written 30 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 | 30 Jan 2015 |
|---|---|
| Reference | 2015-0032 |
| Deceased | Simon Tree |
| Coroner | Simon Wickens |
| Coroner area | Surrey |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
IN THE SURREY CORONER’S COURT IN THE MATTER OF: __________________________________________________________ The Inquests Touching the Death of Simon Richard Tree (Formerly Gary Charles Randall) A Regulation 28 Report – Action to Prevent Future Deaths __________________________________________________________ THIS REPORT IS BEING SENT TO: SABP NHS Foundation Trust. (The Abraham Cowley Unit). 1 CORONER Simon Wickens, HM Assistant Coroner for Surrey 2 CORONER’S LEGAL POWERS I make this report under paragraph 7(1) of Schedule 5 to The Coroners and Justice Act 2009. 3 INVESTIGATION and INQUEST The inquest into Simon Tree’s death was opened on the 21st February 2012 and was resumed on 19th January 2015. It was concluded on 23rd January 2015. The cause of death found was: 1a – Drowing. The conclusion was a narrative as follows: At the time of his death, Simon Tree was a voluntary patient at the Abraham Cowley Unit having originally been sectioned in January 2012 following an attempt at taking his own life. On the 16th February 2012 he was returned to the Unit by Surrey Police having been found by the River Thames in a state of intoxication, expressing a wish to take his own life. As a result he was a known suicide risk and the following morning, 17th February 2012, he was due to be re‐assessed. However, on the RT4496 1 morning of the 17th February, prior to that re‐assessment a member of staff allowed Simon Tree to leave the ward unsupervised thereby giving him access to an area of the unit where there were known concerns about the security of an exit door. In consequence, Simon Tree managed to leave the unit and was found on the 18th February 2012 in the River Thames at Sunbury Island having drowned. It is unclear how he came to be in the river or what his intention was at the time. 4 CIRCUMSTANCES OF THE DEATH At or about 17.25 hours on the 18th February 2012 Mr Tree was found in the river Thames having drowned. He had left the Abraham Cowley Unit the day before having been given access to an area there were known security concerns 5 CORONER’S CONCERNS During the course of the inquest the evidence revealed a matter that gave rise to a concern that circumstances creating a risk of other deaths will continue to exist in the future unless action is taken. The MATTER OF CONCERN is as follows. – During the Course of the Inquest evidence came to light that whilst the door that Simon Tree left the unit from was now secure, there are security issues with the new airlock system. The Court heard that the onus of releasing people from the unit is placed on ward staff, who operate the airlock system remotely from the ward. Patients have been able to ‘tailgate’ visitors leaving legitimately and the Court heard 4 people had managed to leave this way in the last 12 months. On one occasion the camera in the airlock was simply moved to create a blind spot. A reception area exists beyond the airlock where at times there are staff present with a clear view of who is leaving. These staff appear to plays no roll in monitoring those who are leaving thru the airlock. Consideration should be taken to address the issue of patients tailgating in the airlock and address the closer monitoring of those leaving the building. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe that the SABP NHS Foundation Trust has the power to take such action. RT4496 2 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of its date; I may extend that period on request. Your response must contain details of action taken or proposed to be taken, setting out the timetable for such action. Otherwise you must explain why no action is proposed. 8 COPIES I have sent a copy of this report to the Interested Persons in the Inquest and the Chief Coroner. 9 Signed: Simon Wickens DATED this 30th day of January 2015 RT4496 3
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.
Surrey and Borders Partnership NHS} NHS Foundation Trust Our Ref: FE/wc Trust Headquarters 18 Mole Business Park Leatherhead 30 March 2015 Surrey KT22 7AD Mr Simon Wickens HM Assistant Coroner for Surrey Coroners Court Station Approach Woking GU22 7AP Email: Dear Mr Wickens Inquest into the Death of Mr Simon Tree Regulation 28 Report — Action to Prevent Future Deaths Response Further to the conclusion of the inquest into Mr Simon Tree’s death on 23 January 2015, you wrote to Surrey and Borders Partnership NHS Foundation Trust in accordance with the Regulation 28 report to prevent future deaths, stating that during the course of the inquest the evidence revealed matters giving rise to concern. We would firstly, like to take this opportunity to offer our sincere condolences to Mr Tree’s family for their loss. The area of concern you raised that relates to our Trust and our response is detailed below: Consideration should be taken to address the issue of patients tailgating in the airlock and address the closer monitoring of those leaving the building. The risk of absconding is a critical issue in mental health services and we have taken a number of steps in recent years, such as targeted improvement work on reduction of AWOLS. For example we have introduced cards outlining duration & conditions of leave that people take with them when going on leave. This work is targeted at ensuring that we learn from the events that led to Mr Tree leaving the unit, and take steps to try and prevent future incidents such as this taking place through effective care planning and risk management processes. For a better life Trust Headquarters, 18 Mole Business Park, Leatherhead, Surrey KT22 7AD T_0300 55 55 222 F_01372 217111 www.sabp.nhs.uk Since Mr Tree’s death, we have recruited a Security Manager who undertakes annual site security audits at all our inpatient sites. These help us focus our attention on rectifying any weaknesses in our security processes that may enable people to abscond or go AWOL. Further to the issues raised about people tailgating through the airlock, we have employed an out of hours receptionist to support the ward staff during visiting hours and have transferred the administration support to each of the wards between 10am and 3pm to focus on the entrance to and exits from the wards. We have also improved the camera coverage within the airlock itself, so that the whole internal airlock can be viewed through CCTV. We have included the concerns you have raised in our Trust-wide action plan to ensure that there is ongoing learning from these. We would like to offer our sincere condolences again to the Tree family for their loss and hope that the steps we have taken as outlined above assures you and them, that we have learnt and continue to learn from this event. Please do not hesitate to contact me or | md Director of Quality and Deputy Chief Executive (DoN), if you require any further information. Yours sincerely jona Edwards Chief Executive
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