Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0080, written 4 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 | 4 Mar 2015 |
|---|---|
| Reference | 2015-0080 |
| Deceased | Colin Tyson |
| Coroner | Nicola Mundy |
| Coroner area | South Yorkshire (East) |
| 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.
Nicola Jane Mundy Senior Coroner for South Yorkshire (East District) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT 10: I Director Of Quality And Nursing NHS England Oak House Moorhead Way Bramley Rotherham S66 1YY CORONER | am Nicola Jane Mundy, Senior Coroner for South Yorkshire (East District) 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. legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www legislation.gov.uk/uksi/201 3/1629/part/7/made INVESTIGATION and INQUEST On 13/08/2014 | commenced an investigation into the death of Colin Tyson, 51 . The investigation concluded at the end of the inquest on 10 February 2015. The conclusion of the inquest was Suicide. The cause of death was: ta. Severe, extensive external and internal injuries and fractures 1b. Railway collision CIRCUMSTANCES OF THE DEATH Mr Tyson was a private man who had being significantly affected by a physical injury that had limited both his ability to enjoy his sports, for which he had a real passion, and had also led to him being off work for quite some time which was significant for a man who had such a strong work ethic. It was clear that he was struggling to deal with these issues and his perception as to how others might now be viewing him. He attempted to end his life on the 6th August 2014 by way of carbon monoxide poisoning from his car but was taken to hospital and resuscitated. A mental health assessment took place in hospital where he denied further suicidal ideation. An assessment by the general practitioner of the 7th August led to him again being assessed as not requiring any acute psychiatric input. Accordingly no referral was made to the psychiatric services at this time. It became clear during the course of the evidence from family members that Mr Tyson continued to harbour thoughts of suicide and had even been planning how he might do this. On the 11th August 2014 Mr Tyson stepped in front of a high speed train, dying instantly as a result of the impact. The family expressed grave concerns regarding their efforts to pass on information to the GP in the community when they tried to express their concerns to the GP. The concern from the GP practice related to patient confidentiality issues. | am quite satisfied that the family members did have pertinent information which would have benefitted the GP in his assessments. There is a need for there to be a way in which concerned family members of vulnerable persons (even if not falling under the usual category of a child or an elderly patient/person) should be able to pass on relevant information to the general practitioner. Whilst | am not convinced this would have altered the outcome in Mr Tyson's case it may well make all the difference in some cases where per in_a particularly vulnerable state due to life events at that time. The general oractitoner Ail sharoc those concerns and was taking matters back to his private practice but as | felt this raised wider issues for many GP practices ie where GPs might interpret patient confidentiality to extend to not being able to receive critical information. | wish to draw these matters to your attention. Coroner's Court and Office, Doncaster Crown Court, College Road, Doncaster, DN1 3HS Tel 01302 320844 | Fax 01302 364833 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) Concern regarding GPs interpretation of patient confidentiality preventing concerned family members passing pertinent information regarding vulnerable persons who are potentially at risk of suicide. ACTION SHOULD BE TAKEN In - B Dire action should be taken to prevent future deaths and | believe you | Director Of Quality and Nursing 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 07 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 a | have also sent it tof and South West Yorkshire Partnership. | 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 04 Ma Signature Senior Corong South Yorkshire (East District) Coroner's Court and Office, Doncaster Crown Court, College Road, Doncaster, DN1 3HS Tel 01302 320844 | Fax 01302 364833
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.
England 24" September 2015 Yorkshire and the Humber Ground Floor PRIVATE & CONFIDENTIAL 3 Leeds City Office Park Meadow Lane Leeds LS11 5BD Ms. N.J. Mundy Senior Coroner South Yorkshire (East District) Coroners Court and Office College Road Doncaster Dear Ms. Mundy Re: Colin Tyson (deceased) your ref NJM/ph/tji/46194-23014 | am writing to you following your letter on 4" March 2015 requesting details of the action taken following Colin’s death. | have been in contact with NHS Wakefield Clinical Commissioning Group as | outlined in my letter to you of 18" May 2015. | have also had the Opportunity to meet with the family of Mr. Tyson to discuss the actions we have planned to undertake. | will be writing to Mr. Tysons family separately to advise them of the actions we have taken. pe the clinical advisor to NHS Wakefield CCG, has visited the practice concerned and spoken with the GP who assessed and treated Colin who was pleased to have the opportunity to contribute to the joint NHS England and Wakefield CCG response. We have worked together to develop an advice sheet for GP practices on the appropriate response when third parties raise concerns or request sharing of information about a patient registered at the practice. As you rightly noted this is an area which many practices do not feel confident about and hence there is a risk that relevant and important information does not reach the patient’s GP. | attach a copy of this advice sheet for your information. It will be shared with all GP practices in Wakefield by the CCG and across Yorkshire and the Humber by the safeguarding network. In addition we will disseminate this information to all GPs in conjunction with the Local Medical Committees in every district. The advice contained within the advice sheet will also form part of the training that is offered to practices in relation to the safeguarding of adults and children. South West Yorkshire Partnership Foundation Trust who provided the hospital and community mental health services in this case are implementing the actions relating to assessment, communication and follow-up which the review of Colin's death raised. The Head of Quality High quality care for all, now and for future generations and Engagement at Wakefield CCG is monitoring the implementation of these actions to improve care for future patients | have advised Mr. Tyson's family that | would be happy to support any work they undertake to raise awareness of mental health issues with the MIND charity. | am grateful to you for raising these matters with the NHS. | think that the actions taken as a result of your intervention will improve the safety and quality of services for patients in the future. Please let me know if you require any further information. Yours sincerely Uk Associate Medical Director NHS England Yorkshire and the Humber High quality care for all, now and for future generations
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