Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0147, written 20 Apr 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 Apr 2015 |
|---|---|
| Reference | 2015-0147 |
| Deceased | Andrew Farrow |
| Coroner | Peter Hatvany |
| Coroner area | Wiltshire & Swindon |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Avon and Wiltshire Mental Health Partnership NHS 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.
PETER G. HATVANY Assistant Coroner for Wiltshire and Swindon REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Mr lain Tulley, Chief Executive, Avon & Wiltshire Mental Health Partnership NHS Trust, Jenner House, Langley Park, Chippenham, Wiltshire, SN15 1GG Secretary of State for Health, Department of Health, Richmond House, 79 Whitehall, London, SW1A 2NS CORONER lam PETER G. HATVANY, Assistant Coroner for Wiltshire and Swindon 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/2013/1629/part/7/made INVESTIGATION and INQUEST On 14 April 2015 | concluded an investigation into the death of Andrew Ralph Mitchell Farrow, aged 48 . The conclusion of the inquest was Accidental death as a result of acute alcohol and codeine toxicity. CIRCUMSTANCES OF THE DEATH The deceased died as a result of self administered acute codeine and alcohol toxicity at his home on 7 July 2014. 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 deceased was under the care of the Avon and Wiltshire Mental Health Partnership. The day before his death the deceased made it clear he wished to be admitted to hospital for his own safety. The MATTERS OF CONCERN are as follows. — He was known to have suicidal ideation but no actual plan had been formulated. | did not find that he ought to have been admitted. My concern however is that had he needed admitting it is apparent no beds would have been available at Green Lane Hospital Devizes when an enquiry was made on 6 July 2014 by North Wiltshire Intensive Services. Wiltshire & Swindon Coroner's Office, 26 Endless Street, Salisbury, Wiltshire, SP1 1DP Tel 01722 438900 | Fax 01722 332223 ACTION SHOULD BE TAKEN What action would there have been taken in that eventuality? Would enquiries have been made as to the availability of other beds in other areas such as Callington Road, Bristol? YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 15 June 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 | Mother of the deceased | 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 20 April 2015 — Ss Assistant Coroner for Wiltshire and Swindon Wiltshire & Swindon Coroner's Office, 26 Endless Street, Salisbury, Wiltshire, SP1 1DP Tel 01722 438900 | Fax 01722 332223
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.
Avon and Wiltshire NHS Mental Health Partnership NHS Trust Mr P G Hatvany Jenner House Assistant Coroner for Wiltshire & Swindon Langley Park H M Coroner's Office Chippenham Wiltshire ric The Wiltshire & Swindon Coroner’s Court 26 Endless Street Salisbury Wiltshire SP1 1DP RECEIVED 13 JUL 205 8 July 2015 Dear Mr Hatvany Thank you for your letter to our Chief Executive regarding Mr Andrew Farrow deceased and the attached Prevention of Future Death (PFD) report. When there is a bed pressure in a locality, clinical staff may take a number of different actions, depending upon the requirements of the individual patient. These actions may include seeking alternatives to admission such as intensive home treatment, seeking a bed in another part of the Trust, making a bed available by seeing if there are patients well enough to be discharged, or sending a patient out of the Trust’s area. The decision is always risk based, and takes account as far as is possible the wishes of the patient and their family. When a patient is sent out of area, every effort is made to repatriate them locally as soon as it is possible and in their best interests to do so. The Trust Board closely monitors bed pressures and out of area placements and is continually working with its Commissioners and NHS England to manage the situation optimally. ! hope that this information is helpful but please let me know if you require anything further. Whilst writing, | would like to comment at how surprised | was to receive a PFD report for an inquest that we were not a properly interested person in and would like to understand on what basis it was felt necessary to issue a PFD report in this case, given that you found that the patient did not require hospital admission. | have recently taken up appointment at Avon and Wiltshire Mental Health Trust and it is important for me to understand how local Coroners work. | look forward to hearing from you. Yours sincerely Director of Nursing and Quality Continued... Chair Trust Headquarters Chief Executive Anthony Gallagher Jenner House, Langley Park, Chippenham, SN15 1GG lainTulley ‘We are a teaching, learning and research trust; we aim to inform you about relevant opportunities, unless you tell us otherwise.’
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