Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0119, written 12 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 | 12 Feb 2015 |
|---|---|
| Reference | 2015-0119 |
| Deceased | Andrew Frost |
| Coroner | Mary Hassell |
| Coroner area | Inner North London |
| Category | Community health care and emergency services 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: Prevention of Future Deaths report
Andrew Elliot FROST (died 25.09.14)
THIS REPORT IS BEING SENT TO:
1. Ms Wendy Wallace
Chief Executive
Camden & Islington NHS Foundation Trust
4th Floor, East Wing
St Pancras Hospital
4 St Pancras Way
London NW1 0PE
1
CORONER
I am: Coroner ME Hassell
Senior Coroner
Inner North London
St Pancras Coroner’s Court
Camley Street
London N1C 4PP
2
CORONER’S LEGAL POWERS
I make this report under the Coroners and Justice Act 2009,
paragraph 7, Schedule 5, and
The Coroners (Investigations) Regulations 2013,
regulations 28 and 29.
3
INVESTIGATION and INQUEST
On 30 September 2014, I commenced an investigation into the death of
Andrew Elliot Frost, aged 34 years. The investigation concluded at the
end of the inquest yesterday.
I made a determination that Andrew Frost took his own life.
4
CIRCUMSTANCES OF THE DEATH
Mr Frost jumped in front of an underground train early in the morning on
25 September 2014.
1
The day before his death, he had three separate encounters with the
authorities, the first with police; the second with police, paramedics,
general practitioner and crisis team; the third with police and paramedics.
On each occasion, concern was shown for Mr Frost and attempts were
made to assist him.
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.
During the second encounter on 24 September 2014, whilst police and
paramedics were at Mr Frost’s home, Mr Frost and his general
practitioner spoke on the telephone.
The general practitioner was worried about Mr Frost and made an
immediate referral to the Islington Crisis Team at Highgate Mental Health
Centre. He was told that the team did not have sufficient resources to go
out to see Mr Frost that afternoon, but that someone would ring him.
1. There was no shared understanding between the crisis team and
the GP about what the crisis team could and could not do.
The GP thought that the crisis team’s telephone call would include
a conversation sufficiently detailed to allow the crisis team to
decide whether to conduct a mental health act assessment that
afternoon, whereas the crisis team simply intended to arrange an
appointment for the following day.
The GP regarded the crisis team as an emergency service, which
the team leader told me in court is not the case.
It seems that this GP, his partners, and the other general
practitioners who refer patients to crisis teams, would benefit from
a very specific piece of training and education from the crisis team
about their service, including its limitations.
2. The crisis team’s records did not reflect some valuable information
that was passed to them.
For example, that police and paramedics were with Mr Frost at the
time of the GP’s call. This information was communicated by the
GP and by Mr Frost’s partner. If the crisis team had considered
2
this information, they could have advised Mr Frost’s partner he
should tell the paramedics that the crisis team were not coming out
that day, which may have assisted paramedics’ decision making.
3. The pager messaging service used by the crisis team simply takes
the name of the patient and a telephone number to call, nothing
more.
This means that valuable time was wasted by the crisis team,
trying to track down the police officer who had rung to find out
more detail, most especially Mr Frost’s address.
This is time that could be used treating patients.
I did not hear evidence that led me to conclude that different action by
healthcare professionals on 24 September would have changed the
outcome for Mr Frost, but it might for someone else.
6
ACTION SHOULD BE TAKEN
In my opinion, action should be taken to prevent future deaths and I
believe that 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 11 May 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 following.
HHJ Peter Thornton QC, the Chief Coroner of England & Wales
Care Quality Commission for England
Professor Dame Sally Davies, Chief Medical Officer for England
, Mr Frost’s partner
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
3
representations to me, the Senior Coroner, at the time of your response,
about the release or the publication of your response by the Chief
Coroner.
9
DATE SIGNED BY SENIOR CORONER
12.02.15
4
Regulation 28: Prevention of Future Deaths report
Andrew Elliot FROST (died 25.09.14)
THIS REPORT IS BEING SENT TO:
1.
General Practitioner
Killick Street Health Centre
75 Killick Street
London N1 9RH
1
CORONER
I am: Coroner ME Hassell
Senior Coroner
Inner North London
St Pancras Coroner’s Court
Camley Street
London N1C 4PP
2
CORONER’S LEGAL POWERS
I make this report under the Coroners and Justice Act 2009,
paragraph 7, Schedule 5, and
The Coroners (Investigations) Regulations 2013,
regulations 28 and 29.
3
INVESTIGATION and INQUEST
On 30 September 2014, I commenced an investigation into the death of
Andrew Elliot Frost, aged 34 years. The investigation concluded at the
end of the inquest yesterday.
I made a determination that Andrew Frost took his own life.
4
CIRCUMSTANCES OF THE DEATH
Mr Frost jumped in front of an underground train early in the morning on
25 September 2014.
The day before his death, he had three separate encounters with the
authorities, the first with police; the second with police, paramedics,
general practitioner and crisis team; the third with police and paramedics.
1
On each occasion, concern was shown for Mr Frost and attempts were
made to assist him.
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.
During the second encounter on 24 September 2014, whilst police and
paramedics were at Mr Frost’s home, you and he spoke on the
telephone.
You were worried about Mr Frost and made an immediate referral to the
Islington Crisis Team at Highgate Mental Health Centre. You were told
that the team did not have sufficient resources to go out to see Mr Frost
that afternoon, but that someone would ring him.
However, there was no shared understanding between you and the crisis
team about what the crisis team could and could not do.
You thought that the crisis team’s telephone call would include a
conversation sufficiently detailed to allow the crisis team to decide
whether to conduct a mental health act assessment that afternoon,
whereas the crisis team simply intended to arrange an appointment for
the following day.
You regarded the crisis team as an emergency service, which the team
leader told me in court is not the case.
It seems that you, your partners, and other general practitioners who refer
patients to crisis teams, would benefit from a very specific piece of
training and education from the crisis teams about their service, including
its limitations.
I did not hear evidence that led me to conclude that different action by
healthcare professionals on 24 September would have changed the
outcome for Mr Frost, but it might for someone else.
6
ACTION SHOULD BE TAKEN
In my opinion, action should be taken to prevent future deaths and I
believe that you have the power to take such action.
2
7
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date
of this report, namely by 11 May 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 following.
HHJ Peter Thornton QC, the Chief Coroner of England & Wales
Care Quality Commission for England
Professor Dame Sally Davies, Chief Medical Officer for England
, Mr Frost’s partner
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
interest. You may make
representations to me, the Senior Coroner, at the time of your response,
about the release or the publication of your response by the Chief
Coroner.
it useful or of
find
9
DATE SIGNED BY SENIOR CORONER
12.02.15
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.
Killick Street Health Centre 75 Killick Street, London N1 9RH We t: 020 7833 9939 Sal 22,2 f 020 7427 2740 1) oe ig www.killickstreet.co.uk Miss Mary Hassle St Pancras Coroner’s Office and Court Camley Street London N1C 4PP Tel: 020 7974 4545 Fax: 020 7383 2485 Following your requirement for our service to meet with the Crisis Team, | can confirm that we have now met with them on the 19"" March and discussed the service provision with the Crisis Team. | met up with He both senior Managers at the Crisis team. Following discussion about the service we have decided to meet on a more regular basis to discuss the Crisis Team service provision with all the GP’s at the practice and also to enable us to discuss individual clients. We fully understand how the crisis service works. They are an urgent care service that has a requirement to meet a client within 24 hours of referral. However, if someone is too unwell to await this amount of time then the step is to call the Police or the Ambulance service. We are meeting as a clinical service with the Crisis team on the 11" of May at 1.30pm for a meeting to discuss service and clients. We hope to maintain this every 6 months minimum. The Crisis team will be doing their own report to you but | can state that they already invite all GP’s to meet with them on the regular basis and have a relatively low take up on this. They will continue to send invites out, it is up to individual practices whether they meet with them or not. We have agreed to meet with the Crisis team on the regular basis. : h e | hope this letter fulfils the requirements set out in your report dated 12" February 2015. If you require any further information please do not hesitate to contact me. Many thanks. Yours sincerely,
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