Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0093, written 11 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 | 11 Mar 2015 |
|---|---|
| Reference | 2015-0093 |
| Deceased | Leah Levine |
| Coroner | John Pollard |
| Coroner area | Manchester South |
| Category | Mental Health related deaths |
| Organisation named | Greater Manchester West Mental Health NHS Foundation Trust |
| 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 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: The Chief Executive, Greater Manchester West Mental Health NHS Foundation Trust. 1 | CORONER ! am John Pollard, senior coroner, for the coroner area of South Manchester 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 8" October 2014 | commenced an investigation into the death of LEAH LEVINE dob 18” February 1965. The investigation concluded on the 27 February 2015 and an Open Conclusion was recorded. The medical cause of death was 1a Multiple Injuries. 4 | CIRCUMSTANCES OF THE DEATH On the 5™ October 2014 she was staying with a Rabbi friend when she got through a window on to the roof of the house and then either jumped or fell to her death. 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 MATTER OF CONCERN is as follows. — When it was negotiated by the family and friends, with the NHS Trust employees, that she could have temporary leave from the hospital, it was never clearly set out as to what the conditions of that leave should be: who should be responsible for supervising her: What the level and frequency of such supervision should be: what, if any, observation regime should be put in place: and nothing was reduced to writing and given to those taking her from the hospital. Consequent on the above, there was conflicting evidence from different members of the medical and nursing staff as to what exactly was expected and put forward as required. 6 | 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. Urgent consideration should be given to putting in place a requirement for such home leave requirements always to be set out in writing and a copy be given at the time to the person having care of the patient whilst on leave. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 6"" May 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 namely Lyme (mother of the deceased) and el (sister of the deceased). | have also sent a copy to the Care Quality Commission who may find it of interest. | 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, aboyt thé release or the publication of your response by the Chief Coroner. 11.3.15 John Pollard, 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.
Greater Manchester West INHS| Mental Health NHS Foundation Trust Chair and Chief Executives Office Trust Headquarters Bury New Road Prestwich i reer Manchester 30" April 2015 | j ; idl _ ; / i Tel] Mr Pollard . | im Manchester South Coroner : } Web: www.gmw.nhs.uk Mount Tabor Ls- ee orameeat 1 WE ARE SOCIAL Mottram Street | £0 Bottute) Stockport SK13PA £4 has Dear Mr Pollard Re: Ms Leah Levine DOB 18/02/65 (Deceased) 05/10/14 Further to your letter dated 11" March 2015 regarding the Regulation 28: Report to Prevent Future Deaths of the Coroners Rules 2013 in which you raised the following concern: When it was negotiated by the family and friends, with the NHS Trust employees, that she could have temporary leave from the hospital, it was never clearly set out as to what the conditions of that leave should be: who should be responsible for supervising her: What level and frequency of such supervision should be: what, if any, observation regime should be put in place: and nothing was reduced to writing and given to those taking her from hospital. | will therefore outline the action taken by the Trust to address the concern you have raised within your regulation 28. The Salford Directorate has developed a procedure that should be followed when Informal Patients are granted leave with family and friends. This procedure outlines the considerations by the Multidisciplinary team that need to be taken whilst granting leave for a service user in our care. These include medication management, supervision, crisis plan, home based treatment support if applicable. | enclose a copy of the procedure for your information. In order to share the learning from Ms Levine’s death and following the concerns raised during your inquest, the Directorate will inform all Inpatient Nursing and Medical of the procedure which will be implemented by the 315 May 2015. | hope that this response provides assurance to Ms Levine’s family and yourself and that it demonstrates how GMW has put measures in place to ensure that the safety of our services users is fundamental to the care we deliver. Yours sincerel Bev Humphrey Chief Executive Enc: Procedure for Leave for Informal Patients Having Leave with Family or Friends The Trust is committed to safeguarding children, young people and vulnerable adults and requires all staff and volunteers to share this commitment. Greater Manchester West Mental Health NHS Foundation Trust, Trust Headquarters, Bury New Road, Prestwich, Manchester M25 3BL Tel: 0161 773 9121. Triangle of Care \) Chief Executive: Bev Humphrey MEMBER x Chair: Alan Maden
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