Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0149, written 21 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 | 21 Apr 2015 |
|---|---|
| Reference | 2015-0149 |
| Deceased | Bruce Longden |
| Coroner | Veronica Hamilton-Deeley |
| Coroner area | Brighton & Hove |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
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.
VERONICA HAMILTON-DEELEY, LL.B. Her Majesty’s Senior Coroner for the City of Brighton & Hove THE CORONER’S OFFICE WOODVALE, LEWES ROAD BRIGHTON BN2 3QB Assistant Coroners CATHARINE PALMER LL.B (HONS) MICHAEL KEEN KAREN HENDERSON, BSC,BM,MRCPI,FRCA GILVA D.J.TISSHAW, BA(LA W)HONS Telephone: Brighton (01273) 292046 Fax: Brighton (01273) 292047 CORONERS SOCIETY OF ENGLAND AND WALES ANNEX A REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1, Chief Executive, Sussex Partnership 2. Mr. Matthew Kershaw Chief Executive, Brighton & Sussex University Hospital Trust 1 CORONER | am Veronica HAMILTON-DEELEY, Senior Coroner, for the City of Brighton and Hove 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 10" September 2014, | commenced an investigation into the death of Bruce LONGDEN. The conclusion of the inquest was on 17", 18", 19" and 20th March, 2015 4 CIRCUMSTANCES OF THE DEATH See Record of Inquest om -—t 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) Sussex Partnership Trust are apparently unaware of their own protocols in connection with :- VERONICA HAMILTON-DEELEY, LL.B. Her Majesty’s Senior Coroner for the City of Brighton & Hove THE CORONER'S OFFICE WOODVALE, LEWES ROAD BRIGHTON BN2 30B Assistant Coroners CATHARINE PALMER LL.B (HONS) MICHAEL KEEN KAREN HENDERSON, BSC,BM,MRCPI,FRCA GILVA D.J.TISSHA W, BA(LA W)HONS Telephone: Brighton (01273) 292046 Fax: Brighton (01273) 292047 a) Transfer of Sussex Partnership Trust patients to the acute hospital and b) Observations and Therapeutic Engagement policy These policies were not employed. If they had been the outcome may have been different for Mr Bruce LONGDEN as he wouid have been specialled and accompanied and would not have had the opportunity to abscond. 2)Poor communication within Sussex Partnership Trust and to Brighton & Sussex University Hospital Trust 3)Poor communication within Brighton & Sussex University Hospital Trust particularly: « Failure to appreciate the significance of Mr Bruce Longden’s mental health condition e Failure to understand the terminology used by the mental health liaison team e Failure of the Mental Health Team to adhere to commonly understood terminology e Failure to report the absconsion timeously to Sussex Police resulting in a window of opportunity to search for and, potentially, find Mr Bruce Longden to be lost 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you AND 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 8” July 2015. |, Veronica HAMILTON-DEELEY 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 | have sent a copy of my report to the Chief Coroner and to the following Interested Persons The Chief Executive, Care Quality Commission Julian Lee — Chair of Brighton & Sussex University Hospitals Secretary of State for Health, Department of Health Sir David Nicholson/Simon Stevens — Chief Executive NHS England National Patient Safety Agency — Medico Legal Services Manager Director of Clinical Quality & Primary Care Director of Public Health Legai Support Manager LON DAPRwn = VERONICA HAMILTON-DEELEY, LL.B. THE CORONER’S OFFICE Her Majesty’s Senior Coroner WOODVALE, LEWES ROAD for the City of Brighton & Hove BRIGHTON BN2 3QB Assistant Coroners CATHARINE PALMER LL.B (HONS) MICHAEL KEEN KAREN HENDERSON, BSC,BM,MRCPI,FRCA GILVA D.J.TISSHAW, BA(LA W)HONS Telephone: Brighton (01273) 292046 Fax: Brighton (01273) 292047 | have also sent it to:- 10. Burnard Brazier Tisdall - Executors Who may find it useful or of interest. 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 Date: 2ist April, 2015 SIGNED BY: Senior Coroner B'
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.