Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0071, written 26 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 | 26 Feb 2015 |
|---|---|
| Reference | 2015-0071 |
| Deceased | Simon Costin |
| Coroner | Catherine Mason |
| Coroner area | Leicester (City & South) |
| 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.
Mrs, C.E. Mason Senior Coroner for Leicester (City and South) eee REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Mr Simon Stevens , Chief Executive, NHS England 1 CORONER | am Mrs. C.E. Mason, Senior Coroner for Leicester (City and South) 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. http://www. legistation.gov_uk/ukpga/2009/25/schedule/5/paragraph/7 http://www. legislation.gov_uk/uksi/2013/1629/parl/7/made [3 INVESTIGATION and INQUEST On 27/03/2014 | commenced an investigation into the death of Simion Costin, 39. The cause of death was - Incised wound to the neck The investigation concluded at the end of the inquest on 24 February 2015. The conclusion of the inquest was "Took his own life while his mind was in a state of imbalance” 4 CIRCUMSTANCES OF THE DEATH Simion Costin died at the Leicester Royal Infirmary on the 25th March 2014 after being admitted with a self-inflicted neck incision. Mr Costin had attended the hospital on two occasions in the preceding 4 days. On both occasions he had been discharged after mental health assessment. On the second occasion an opinion and discharge plan was made on incomplete data. As a result there was a missed opportunity for things to have been done differently and the chance of a better outcome was lost. 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) Evidence was heard that during patient assessment, the same approach was not adopted by all clinicians. As a result standardised assessments forms have now been developed and are being used within the Leicestershire Partnership Trust. This includes the need to involve family / friends in the assessment (with the consent of the patient). However, it was recognised that mental health care often crosses boarders with an initial assessment made in a neighbouring hospital but then the patient transferred for care and treatment elsewhere. The Consultant gave evidence that it would be better if there were nationally agreed standard forms so that communication in these complex situations is best served. Town Hall Square, Leicester, LEL 9BG Tel 0116 4541030 | Fax 0116 225 2537 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 21 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 and to the following Interested Persons: Leicestershire Partnership Trust Care Quality Commission | 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. Dated 26 Februapy Signatu Senior Leicester (City and South) Town Hall Square, Leicester, LEI 9BG Vel O116 4541030 | Fax 0116 225 2537
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.
INHS: England Bruce Keogh Medical Directorate 6" Floor, Skipton House 80 London Road SE1 6LH Mrs. Catherine E. Mason LL.B; HONS; 20" April 2015 RGN Senior Coroner H.M. Coroner For Leicester City and South Leicestershire Town Hall Square Leicester LE1 9BG Dear Mrs C.E Mason, Re: Simion Costin Report re As NHS England's National Medical Director | have been asked to respond to the above report on behalf of Further to your letter dated 26 February 2015 and the issue of the Regulation 28 report to prevent future deaths, | would like to offer my sincere condolences to Simion Costin's family From our review and consideration of the report, we note that the issue of standardised mental health assessments has been addressed by Leicestershire Partnership Trust. However, in view of the serious nature of this case, | have consulted with NHS England's Midlands and East Regional Medical Director, EEN with a view to ascertaining further actions needed to address the issues raised in the report. The NHS Trust Development Authority (TDA) has been in contact with the Leicestershire Partnership Trust and is assured that specific learning points from this incident have been identified. These include: * the use of translators; ¢ liaison with Primary Care; and * the active involvement of friends and family following any acute assessment Furthermore, the Leicestershire Partnership Trust has signed up to the Crisis Care Concordat and agreed a Local Action Plan to support people in mental health crisis. The Leicestershire Partnership Trust Local Action Plan includes actions to ensure: those groups known to be at higher risk of suicide than the general population will be identified; * NICE Quality statement 6 is met — “ People in crisis who are referred to MH services are assessed face to face within 4 hours in a community location that suits them best”; High quality care for all, now and for future generations ¢ adequate Liaison Psychiatry is in place; ¢ development, through contract negotiation, regarding how crisis plans and advance statements can be shared when needed; and * implementation of the guidance on commissioning crisis care services for Black and Minority Ethnic (BME) groups. The Crisis Care Concordat is a national commitment between all services and agencies that come into contact with people in crisis. It sets out how they will work together and be involved in the care and support of people in crisis, and how they ensure people get the Support they need, when they need it As one of the signatories to the Crisis Care Concordat, NHS England is committed to working with other agencies who come into contact with people experiencing a mental health crisis, to improve the system of care and support for people in crisis, to work together to identify the causes of crises, and put in place prevention and early intervention plans whenever possible | am grateful to you for bringing this case to my attention Yours sincerely, Bruce Keogh National Medical Director NHS England High quality care for all, now and for future generations
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