Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0065, written 19 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 | 19 Feb 2015 |
|---|---|
| Reference | 2015-0065 |
| Deceased | Barrie Lewis |
| Coroner | Andrew Barkley |
| Coroner area | Powys, Bridgend & Glamorgan Valleys |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
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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. Chief Executive of Cwm Taf Health Board 2. Chief Coroner 3. EE (Partner) 1 | CORONER ! am Andrew Barkley, Senior Coroner, for the coroner area of Powys, Bridgend and Glamorgan Valleys 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 the 9" September 2014 | commenced an investigation into the death of Barrie Lewis. The investigation concluded at the end of the inquest on the 18” February 2015. The conclusion of the inquest was “suicide”. 4 | CIRCUMSTANCES OF THE DEATH The deceased was found by his family hanging in a garage at the rear of his property on the morning of the 31° August 2014. He was hanging from a rope attached to a rafter within the garage. 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. — [BRIEF SUMMARY OF MATTERS OF CONCERN] (1) A clinical review was undertaken of the contact the deceased had with the mental health services in the days prior to his death and it was apparent from that review, and from the evidence heard that: a) That no risk assessment was undertaken to detail risks specifically associated with the deceased’s suicidal ideation which, on the evidence, would have assisted the crisis team in assessing his risk of suicide or self harm. b) There was little formal mechanism for communication between the mental health out patients department and the acute services which he accessed in the days prior to his death. c) There was no reliable system to ensure that a member of the crisis team took responsibility for providing assistance to the deceased — simply leaving the deceased to make his own telephone call to the appropriate department. d) Noclinical recordings were made of the contact the deceased had with the crisis team (Crisis Resolution Home Treatment team) following his contact with them. 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. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 16" April 2015. |, 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, Cwm Taf Health Board and the family. lam 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. 19° February 2015 SIG Mr Andrew Barkley . HM Senior Coroner
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.
I~\GIG ol"'tA. e y M R u ~f'"NHS 'öl WALES Bwrdd lechyd Prifysgol Cwm Taf University Health Board Your refì'eich cyf: Our refì'eincyf: Date/Dyddiad: TeLlffôn: Fax/ffacs: Email/ebost: Dept/adran: 16th April 2015 01443744800 01443 744889 Patient Care & Safety Private &. Confidential Mr Andrew Barkley HM Coroner for Cardiff and the Vale of Glamorgan Aberdare Police Station Cross Street Aberdare CF447EG Dear Mr Barkley, Re: Regulation 28 Coroner's Rules: Mr Barrie Lewis I refer to your correspondence received on 19th February 2015, enclosing the Regulation 28 report, which details the areas of concern following your conclusion of the inquest on 18th February 2015 relating to the death of Mr Barrie Lewis on 31st August 2014. Please be assured that seriously and has learnt at the inquest minimise the risk of any recurrence. the Health Board has taken this matter extremely lessons following investigation and the matters raised into the circumstances. A robust action has been developed to 1. Action taken to plan and monitor improvements A corrective Action Plan for Health Boards comprehensive response; this is attached. Improvement was developed to capture the 2. Actions implemented the actions have been taken forward by the Health Board to the Care I can confirm that improve communication Treatment department, development of a new procedure on the role of the duty officer and improved monitoring of recording systems and processes. Plan Policy and Procedures within including a review of and documentation outpatients The progress made with implementing the action plan as at 16th April 2015 is reflected in the action plan as attached. reassure I sincerely hope that you that lessons from the investigation into the care provided to Mr Lewis and that effective action has now been taken to mitigate reoccurrence of similar tragic incidents. this information and enclosed Action Plan will the Health Board has learnt important Return Address: Ynysmeurig House, Navigation Park, Abercynon, CF45 4SN Chair/Cadeirydd: Dr C D V Jones, CBE Chief Executive/PrifWeithredydd: Mrs Allison Williams Cwm Taf University Health Board is the operational name of Cwm Taf University Local Health Board/Bwrdd Iechyd Prifysgol Cwm Taf yw enw gweithredol Bwrdd lechyd Lleol Cwm Taf
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