Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0073, written 2 Mar 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 Mar 2015 |
|---|---|
| Reference | 2015-0073 |
| Deceased | Peter Wright |
| Coroner | Andrew Haigh |
| Coroner area | Staffordshire (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.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
1. Mr Neil Carr OBE, Chief Executive, South Staffordshire and Shropshire
NHS Foundation Trust
CORONER
| am Mr Andrew Haigh senior coroner for the coroner area of Staffordshire South
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.
INVESTIGATION and INQUEST
On 3 December 2013 | commenced an investigation into the death of Peter
Jonathan Wright aged 49 years. The investigation concluded at the end of the
inquest on 26 February 2015. The conclusion of the inquest was ‘suicide while
suffering severe depression and psychosis’.
CIRCUMSTANCES OF THE DEATH
Mr Wright was certified dead at 22.40 hours on 29 November 2013 at St George’s
Hospital in Stafford. He had been a voluntary patient there and had deliberately cut
an artery in his neck using a broken metal fork. He had been observed by staff
shortly prior to the incident but because of work pressure on staff the observations
had not been recorded. No doctor from the hospital was available to attend the
scene.
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) At the time of the death the ward was understaffed. Of the quota staff of three,
one care assistant had been called to assist in another ward (and had in fact
just returned) and one care assistant was with another patient who required
continuous observation. This left just the qualified nurse to deal with 16
patients. She did not record all necessary observations and was doing a drugs
round by herself (contrary to policy). This was recognised in the SIR carried
out by Pe no recommendation was made about it on the basis that
the Trust was undergoing a major staffing review in any event. It may therefore
be that the situation has already been addressed but this was not clear to me at
the Inquest and the impression | received from the nurse was that there is now
some extra support at times but it is still not satisfactory.
(2) At the time of this incident there was still a 24 hour Emergency Department at
the nearby Stafford Hospital and at St George’s Hospital there was no doctor on
site. Now the Emergency Department at County (formerly Stafford) Hospital is not
open during the night and the nearest ED is at Stoke. | was told that the situation
can be managed by calling paramedics. While | appreciate that nearly all the
doctors at St George’s are psychiatrists not medics | wonder if any consideration
has been given to out of hours cover by a doctor?
6 | 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.
7 | YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this
report, namely by 27 April. |, 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.
8 | COPIES and PUBLICATION
| have sent a copy of my report to the Chief Coroner and to the following Interested
Persons:
widow of the deceased
Osborne Morris and Morgan solicitors for the family
Weightmans solicitors for the Trust
| 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.
9 | 2 March 2015
Andrew A Haigh
HM Senior Coroner
Staffordshire (South)
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.
South Staffordshire and Shropshire Healthcare NHS) NHS Foundation Trust A Keele University Teaching Trust 20" April 2015 Neil Carr Our Ref: Fs Chief Executive Trust Headquarters STRICTLY CONFIDENTIAL St Paria Hospital , orporation Street Mr. Andrew .A. Haig Senior Coroner Stafford H.M. Coroner's Office ST16 3SR No 1 Staffordshire Place Tel: FY Stafford : ST16 2LP Dear Mr Haig, Re: Peter Jonathan WRIGHT (Deceased) Thank you for your letter dated 2" March 2015, reporting concerns to us, in accordance with Regulations 28 and 29 of the Coroner's (Investigations) Regulations 2013. Following discussions within the Mental Health Division, HEM (Medical Director) and (Director of Nursing & Chief Operating Officer), | am now in a position to respond to your specific concerns as outlined below: 1. At the time of the death the ward was understaffed. Of the quota staff of three, one care assistant had been called to assist in another ward (and had in fact just retuned) and one care assistant was with another patient who required continuous observation. This left just the qualified nurse to deal with 16 patients. She did not record all necessary observations and was doing a drugs round by herself (contrary to policy). This was recognised in the SIR carried out by (EM but no recommendation was made about it on the basis that the Trust was undergoing a major staffing review in any event. It may therefore be that the situation has already been addressed but this was not clear to me at the Inquest and the impression | received from the nurse was that there is now some extra support at times but it is still not satisfactory. The Trust undertakes nurse staffing establishment reviews for each of our in-patient ward areas on at least a six-monthly basis. In undertaking these reviews, the Trust uses: e quality metrics (such as clinical incidents, patient experience information, complaints and workforce data such as sickness, vacancy rates and turnover) and e data taken from an evidence based workload calculator tool, in combination with e professional judgement arising from their clinical experience regarding staffing levels Once the review has been undertaken, the team's recommendations are published and reviewed by the Trust Board regarding the most effective level of nurse staffing establishment required to meet the needs of our patients. During the last review which was presented at Trust Board in December 2014, there were additional investments made to the nursing establishments on a number of our wards. For 2015/16 Brocton Ward staffing establishment is 4/4/3 (with two registered nurses on duty at all times). This is the minimum level which can be expected on the ward Page 1 of 2 South Staffordshire and Shropshire Healthcare NHS NHS Foundation Trust A Keele University Teaching Trust with additional staff being deployed to meet any increased acuity. There are also non- nursing clinical staff who will be present on the ward undertaking other duties — examples will include medical and allied health professionals providing therapeutic interventions. 2. At the time of this incident there was still a 24 hour Emergency Department at the nearby Stafford Hospital and at St George's Hospital there was no doctor on site. Now the Emergency Department at County (formerly Stafford) Hospital is not open during the night and the nearest ED is at Stoke. | was told that the situation can be managed by calling paramedics. While | appreciate that nearly all the doctors at St George's are psychiatrists not medics | wonder if any consideration has been given to out of hours cover by a doctor The Trust does not have resident doctors on call but operates a non-resident out of hour’s rota to comply with European Working Time Directive. The psychiatrists on call out of hours at St George's Hospital are all qualified doctors. The most immediate tier of the rota involves doctors in training (Core Trainees in Psychiatry) who operate a non-resident rota but who in reality are often on site and they are supported by middle grade and consultant staff. Our medical and nursing staff are all trained in basic life support as part of mandatory training and some have intermediate and advanced skills. Every clinical and non-clinical area has first aid in place and wards are stocked with equipment for managing common emergencies. We do however recognise that more sophisticated medical equipment and support may be required at times, and in the case of a medical emergency we expect staff to call 999 without delay, as this is what people in the community would do in similar circumstances. On occasions when a medical emergency occurs we call 999 without delay, and staff are instructed to provide basic life support until paramedics arrive. The closure of A&E at County Hospital will inevitably mean that patients from this area will travel further than before in order to reach A&E but the stabilising treatment on site and prior to transfer is important, and paramedics are best placed to provide this. Our experience is that response times have been satisfactory. | hope this response helps to address your concerns. However if you require any further information please do not hesitate to contact me Yours sincerely Neil Carr Chief Executive Page 2 of 2
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