Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0092, written 20 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 | 20 Feb 2015 |
|---|---|
| Reference | 2015-0092 |
| Deceased | Laura Hill |
| Coroner | Gareth Lewis |
| Coroner area | Carmarthenshire & Pembrokeshire |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Chief Executive Hywel Dda University Health Board 1 CORONER I am Gareth Glyn Lewis Area Coroner for the coroner area of Carmarthenshire and Pembrokeshire. 2 CORONER’S LEGAL POWERS I 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 19th December 2012 an investigation into the death of Laura Hill then aged 21 was commenced. The investigation concluded at the end of the inquest on 27th November 2014. The conclusion of the inquest was a narrative verdict namely that the deceased had suspended herself by a ligature from the branch of a tree in a wooded area near to the Springfield Retail Park on Fishguard Road, Haverfordwest but the question of intent remains unclear. The medical cause of death was hanging. 4 CIRCUMSTANCES OF THE DEATH (1) The deceased had had a difficult time growing up which saw her bullied at school, suffer depression and begin taking controlled drugs. She also lost a young son in January 2011 and her boyfriend of the time took his own life in August 2012. (2) On 11th December 2012 the deceased took a large overdose of prescription tablets which nearly killed her. She was admitted to and treated at Withybush General Hospital for a period of 4 days and then transferred as a voluntary patient to the St Caradog Ward (‘the Ward’) at Bro Cerwyn Hospital in Haverfordwest. (3) On arrival at Bro Cerwyn, the deceased was assessed as having “varying suicide risk” and it was felt that she would benefit from admission in view of her depression, substance misuse, unresolved bereavement issues and recent suicide attempt. She was placed on Level 2:15 observations. At this time she was described as “jovial, bright and interacting well with others”. (4) At 19.15 hours that day the deceased demanded to leave the Ward in order to source heroin. Staff on the Ward tried to dissuade her from leaving but she was adamant. She was allowed to discharge herself against medical advice. (5) In the early hours of 16th December the deceased was returned to the Ward by Police Officers who had detained her under section 136 of the Mental Health Act. (6) Upon readmission to the Hospital the deceased was emotional, in a distressed state, sobbing and tearful. The assessing doctor, placed her back on Level 2:15 observations and stated that should she seek to leave again then consideration 1 (7) At 14.45 hours on 16th December 2012, the deceased absconded from the Ward. Staff on Ward did not see her leaving the Ward. The alarm was raised by other patients. Staff from the Ward pursued her and persuaded her to return back to the Ward. The assessing doctor was not notified of this attempt to abscond nor was there a further assessment of the deceased’s mental health. (8) At approximately 18.15 hours later that day the deceased absconded from the Ward again. When a member of staff got to the door of the Ward she was nowhere to be seen. The Police were notified and there was an extensive search to try and locate her. (9) The deceased was found hanging from the branch of a tree in a wooded area near to the Springfield Retail Park at approximately 07.55 hours by members of the public. 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) That there appears to be a breakdown in the transition and passing of information between the Child/Adolescent and the Adult Mental Health Teams. (2) Staffing levels on the Ward need to be reviewed as it was felt that staffing resources were stretched at the relevant time (1 nurse and 3 support workers on a 16 bed acute ward). (3) There was a training need identified in relation to the section 136 procedure when patients are handed over by the Police. (4) There was a training need identified in relation to what constitutes ‘absconding’ and what should be done by staff following an incident of absconding. (5) The door policy on the Ward needs to be reviewed as a patient was able to abscond without staff noticing. (6) There was a training need identified in relation to Personality Disorders. (7) There was a training need identified in relation to powers of detention and when those powers can and should be used. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe 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 the 10th April 2015. I, 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 I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: c/o Lester Morrill Solicitors, 27 Park Square West, Leeds, LS1 2PL c/o JCP Solicitors, Venture Court, Waterside Business Park, Valley Way Enterprise Park, Swansea, SA6 8QP 2 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 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 20th February 2015 Signed: 3
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.
GIG | Bwrad techyd Prifysgol “ Hywel Dda NHS University Health Board Ein cyf/Our ref: | ‘Swyddfeydd Corfforaethol, Adeilad Ystwyth . . Hafan Derwen, Parc Dewi Sant, Heol Ffynnon Job Gofynnweh am/Please ask for: [EEE PA to Chief Executive Caertyrddin, Sir Gaerfyrddin, SA31 3BB Rhif Ffén ‘Telephone: f Ffacs/Facsimile: Corporate Offices, Ystwyth Building -bostiE-mail: Hafan Derwen, St Davids Park, Job's Well Road, E-bostiE-mail: Fe Carmarthen, Carmarthenshire, SA31 3BB Dyddiad/Date: 08 Aprit 2015 Mr Gareth Glyn Lewis Area Coroner - Carmarthenshire and Pembrokeshire Coroner's Office Town Hall Hamilton Terrace Milford Haven Pembrokeshire SA73 3]W Dear Mr Lewis Re: Regulation 28 Report to Prevent Future Deaths Thank you for the Regulation 28 Report that I received from you following the Inquest into the death of Laura Hill. Your report identified a number of matters of concern and I shall address them each in turn. 1, That there appears to be a breakdown in the transition and Passing of information between the Child and Adolescent and Adult Mental Health Teams. In January 2013, the Health Board provided transition guidelines in relation to Specialist Child and Adolescent Mental Heaith Services to Adult Mental Health and Learning Disability Services. The document was circulated across all the relevant teams and provides clear transition guidelines in line with best practice and government guidelines with regards to transitions between services. It is recognised that times of transition can pose potential risks if they are not robustly managed and the guidance enhances the safety of the transition process with clear steps for professionals to follow. 2. Staffing levels on the ward need to be reviewed as it was felt that staffing resources were stretched at the relevant time (1 nurse and 3 support workers on a 16 bed Acute Ward). Swyd¢feydd Corfforaethal, Adeilad Ystwyth, Corporate Offices, Ystwyih Building, Cadeirydd / Chair Hafan Derwen, Parc Dewi Sant, Heo! Ffynnon Job, Hafan Derwen, St Davids Park, Job's Well Road, Mrs Bernardine Rees OBE Caerfyrddin, Sir Gaerfyrddin, SA31 38B Carmarthen, Carmarthenshire, SA31 3BB. Prif Weithredwr/Chief Executive Mr Steve Moore Bwrdd lechyd Prifysgol Hywel Dda yw enw qweithredol Bwrdd lechyd Lleot Prifysaol Hywel Dda Hywel Dda University Health Board is the operational name of Hywel Dda University Locai Health Board Mae Bwrdd lechyd Prifysgol Hywel Dda yn amoylchedd diwg Hywel Dda University Health Board operates a smoke free environment Since the incident occurred, the ward has reviewed (May 2013) the shift pattern and now works on the basis of four staff as a minimum per shift, with an additional staff member on a flexible shift to cover the busier part of the day. This cover relates to nursing staff only. Additionally, the ward would have the manager and other disciplines providing input. Staffing levels have to be flexible and dependant upon patient activity and complexity. This requires increasing staffing levels at short notice, particularly where one to one observations are required. There are systems in place on a twenty four hour basis to sanction increased staffing levels when they are required. The ward has also reduced to fifteen beds since the incident. 3. There was a training need identified in relation to the Section 136 procedure when patients are handed over by the Police. A multi-agency Section 136 Protocol was signed off in November 2014. This Protocol details partner responsibilities in relation to Section 136. There are clear guidelines to be followed and these include points of transition with associated documentation. Nursing staff on St Caradog Ward receive training in respect of their responsibilities as part of their induction. Further follow up training is thereafter provided directly to staff on the ward. Medical staff also receive training on induction as well as on-going through the Post Graduate Medical Training Forum. Medical staff have protected training on a weekly basis. 4. There was a training need identified in relation to what constitutes ‘absconding’ and what should be done by staff following an incident of absconding. Guidance in relation to the management of those patients who abscond from the in-patient ward has been provided to ail relevant staff by the Head of Acute Care Services. 5. The Door Policy on the ward needs to be reviewed as a patient was able to abscond without staff noticing. St Caradog is an open adult admission ward. It is not a secure or locked ward. The ward has the option to lock its door, although this.has to be done in line with guidance, as provided by the 1983 Mental Health Act - Code of Practice. An up to date policy is in place to guide staff in relation to the locking of doors on such units as well as the recording of these instances. All patients are risk assessed and assigned observation levels in line with the outcome of the risk assessment. Both risk and observation levels are subject to continuous review. x 6. There was a training need identified in relation to Personality Disorders. Since the incident, there has been an enhancement of training in relation to personality disorder that has taken place within the Mental Health and Learning Disabilities Directorate. These include: Dialectical Behavioural Therapy, Emotional Coping Skills and Knowledge and Understanding Framework for Personality Disorders. The Health Board is committed to developing the use and range of psychological intervention and, in line with Welsh Government guidance, has a Committee dedicated to enhancing the delivery of psychological therapies across the whole service. Additionally, St Caradog, as well as other adult mental health wards, has dedicated psychology input both to provide patient assessment and intervention as well as supporting ward based staff with guidance in relation to clinical care planning and optimum approaches to patient care. 7. There was a training need identified in relation to powers of detention and when those powers can and should be used. Registered clinica! practitioners are aware of the powers of detention which are available to them. On-going Mental Health Act and Mental Capacity Act training (as detailed previously) ensure that clinicians are updated in relation to the application of powers of detention. I trust that the above response satisfactorily addresses the matters of concern that you have raised. If there are any further queries, please do not hesitate to contact me. Yours sincerely Steve Moore Chief Executive
See every Prevention of Future Deaths report matching Hospital Death (Clinical Procedures and medical management) related deaths, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.