Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0117, written 12 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 | 12 Mar 2015 |
|---|---|
| Reference | 2015-0117 |
| Deceased | Ronald Gittens |
| Coroner | Andrew Walker |
| Coroner area | London (North) |
| 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.
. ' North London Coroners Court, Her Majesty's Coroner for the 29 Wood Street, Northern District of Greater London Barnet ENS 4BE . (Harrow, Brent, Barnet, Haringey and Enfield) Telephone 0208 447 7680 Fax 0208 447 7689 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Barnet Enfield and Haringey Mental health trust Block B2, St. Anns Hospital, Saint Ann's Road, London N15 3TH NO Department of Health Richmond House 79 Whitehall London SW1A 2NS 4 CORONER | am Andrew Walker, senior coroner, for the coroner area of Northern District of Greater London 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 the 12” April 2012 | opened an inquest touching the death of Ronald Gittens , 31 years old. The inquest concluded on the 22™ September 2014. The conclusion of the 5 inquest was “Narrative ’, the medical case of death was 1a Cerebral Hypoxia 1b Hanging 4 | CIRCUMSTANCES OF THE DEATH On the 5" April 2012 Mr Gittens was brought by ambulance to St Thomas’ hospital when a passer by telephoned for an ambulance having seen and spoken to Mr Gittens in the street. A doctor at St Thomas’ assessed Mr Gittens and Mr Gittens agreed to an informal admission and was placed on one-to-one observation. Had no bed been available at Chase Farm Hospital where Mr Gittens was to be transferred Mr Gittens would have been admitted to St Thomas’ Mr Gittens was transferred to Chase Farm Hospital where he was assessed again and the plan was for an informal admission. Mr Gittens was left to wait for a bed and intermittently monitored. Staff at Chase Her Majesty’s Coroner for the Northern District of Greater London (Harrow, Brent, Barnet, Haringey and Enfield) Farm Hospital did not know that Mr Gittens had been on one-to-one observation prior to his transfer. Mr Gittens left the hospital before being admitted. Mr Gittens was found on the 7" Apri! 2012 at his home having hanged himself using a length of rope from the loft hatch handle. The delay in admitting Mr Gittens and the fact that Mr Gittens was not on one-to-one observation whilst waiting to be admitted contributed to Mr Gittens leaving the hospital, and bearing in mind Mr Gittens state of mind, to his 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 MATTERS OF CONCERN are as follows. — * The use of CRHTT as a filter to prevent patients in need of a bed from having access to a bed. 6 | ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you * The transfer of acute psychiatric patients when no bed is available and [AND/OR 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 Thursday 7" May 20165. |, 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 1 t i i t ‘ | | | have sent a copy of my teport to the Chief Coroner and to the following Interested | Persons;- Representatives of the family and the Mental Health Trust. i | HW 1am 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 12 Margh 2645
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.
age From Rt Hon Alistair Burt MP Minister of State for Community and Social Care Department of Health Richmond House 79 Whitehall London SWIA 2NS POC3000935580 Tel: 020 7210 4850 Mr A. Walker North London Coroners Court 29 Wood Street Barnet ENS 4BE 20 MAY 2015 ous Wr Welle _ Thank you for your letter of 12 March 2015 following the inquest into the death of Ronald Gittens. I was very sorry to hear of Mr Gittens’ death and wish to extend my sympathy and sincere condolences to his family. You raise two matters of concern: e The transfer of acute psychiatric patients when no bed is available and; e The use of a Crisis Resolution Home Treatment Team (CRHTT) as “a filter to prevent patients in need of a bed from having access to a bed”. You have also sent your report to the Barnet, Enfield and Haringey Mental Health Trust. The concerns you raise are properly matters for the local Trust and I would expect them to respond appropriately to you. We give Trusts the freedom and discretion to arrange these matters in ways that best meet the needs of patients. However we insist that all patients receive timely, high-quality care. Where that does not happen, as in this case, Trusts must take action to put things right. I appreciate that the issue of inter-trust transfers of at-risk psychiatric patients is indeed one relevant to all Mental Health NHS Trusts. However, the responsibility for decision making in this area resides with the local NHS rather than the Department of Health. The Department of Health is committed to improving the care and support of people in mental health crisis. In February 2014, we launched the Crisis Care Concordat. The Concordat is a national commitment, agreed 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 that these people get the support they need, when they need it. A key ambition of the Concordat is for every local area to agree and deliver its own Mental Health Crisis Action Plan to improve crisis care in that area. Every locality in England now has such a plan in place. These plans include proposals for reviewing the provision of home treatment teams, hospital places of safety (so that people in mental health crisis are not detained in police celis), and round the clock telephone helplines for people in crisis. NHS England is one of the signatories to the Concordat to improve the system of care and support for people in crisis. Their work includes identifying the causes of crises, and putting prevention and early intervention plans in place whenever possible. I am grateful to you for bringing the circumstances of Mr Gittens’ death to my attention and I hope that you find this reply helpful. ALISTAIR BURT
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