Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0038, written 2 Feb 2015. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 2 Feb 2015 |
|---|---|
| Reference | 2015-0038 |
| Deceased | Tanya Page |
| Coroner | Mary Hassell |
| Coroner area | Inner North London |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Camden and Islington NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Regulation 28: Prevention of Future Deaths report
Tanya Christine PAGE (died 20.05.14)
THIS REPORT IS BEING SENT TO:
1. Ms Wendy Wallace
Chief Executive
Camden & Islington NHS Foundation Trust
4th Floor, East Wing
St Pancras Hospital
4 St Pancras Way
London NW1 0PE
1
CORONER
I am: Coroner ME Hassell
Senior Coroner
Inner North London
St Pancras Coroner’s Court
Camley Street
London N1C 4PP
2
CORONER’S LEGAL POWERS
I make this report under the Coroners and Justice Act 2009,
paragraph 7, Schedule 5, and
The Coroners (Investigations) Regulations 2013,
regulations 28 and 29.
3
INVESTIGATION and INQUEST
On 27 May 2014, I commenced an investigation into the death of Tanya
Christine PAGE. The investigation concluded at the end of the inquest on
29 January 2015.
The determination made by the jury at inquest was that, Tanya Page took
her own life while suffering from psychotic depression on the background
of emotionally unstable personality disorder.
4
CIRCUMSTANCES OF THE DEATH
Tanya Page hanged herself whilst detained under a section of the Mental
Health Act on Opal Ward of Highgate Mental Health Unit.
1
5
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. When Ms Page was transferred from Sapphire to Opal Ward, she
disclosed that she had tried to hang herself whilst on Sapphire a
few days before. Opal Ward staff members were shocked at this
but, though they recorded the disclosure in the medical notes, they
did not alert any staff member from Sapphire until after Ms Page’s
death.
From the evidence given by the consultant psychiatrist on Opal
Ward, there appeared to be a reluctance to draw attention to this
information, because of the perception that it carried with it a
criticism of the staff on Sapphire.
However, it was important that staff on Sapphire were told, both
from the point of view of Ms Page herself, and because this was a
valuable piece of learning for them that could affect how they
cared for other patients. The worry about perceived blame should
not have prevented prompt discussion.
There were other learning points discussed during the inquest, such as
the necessity to search the laundry room as well as bedroom of a patient
feared to be at risk of self harm; the potential for wardrobe doors to act as
a ligature point and the desirability of sharing that learning nationally; and
the training issues around use of alarms, ligatures, general patient safety
and resuscitation techniques. However, evidence was given that steps
have already been taken by the trust to act upon these and so I do not
need to comment on them further.
6
ACTION SHOULD BE TAKEN
In my opinion, action should be taken to prevent future deaths and I
believe that 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 3 April 2015. I, the coroner, may extend the
period.
2
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
I have sent a copy of my report to the following.
HHJ Peter Thornton QC, the Chief Coroner of England & Wales
Care Quality Commission for England
Professor Dame Sally Davies, Chief Medical Officer for England
, consultant psychiatrist, Opal Ward
Tanya Page’s parents
I 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
interest. You may make
he believes may
representations to me, the Senior Coroner, at the time of your response,
about the release or the publication of your response by the Chief
Coroner.
it useful or of
find
9
DATE SIGNED BY SENIOR CORONER
02.02.15
3
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