Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0171, written 27 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 | 27 Apr 2015 |
|---|---|
| Reference | 2015-0171 |
| Deceased | Tamara Holboll |
| Coroner | Mary Hassell |
| Coroner area | Inner North London |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Camden and Islington NHS Foundation Trust |
| 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
Tamara HOLBOLL (died 09.05.14)
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 10 May 2014, one of my assistant coroners, William Dolman,
commenced an investigation into the death of Tamara Holboll, aged 47
years. The investigation concluded at the end of the inquest on 20 April
2015. I made a narrative determination, which I attach to this letter.
4
CIRCUMSTANCES OF THE DEATH
Tamara Holboll died from stab wounds to the neck and chest. Her son,
, pleaded guilty to her manslaughter on the ground of
diminished responsibility. He has been detained in a secure hospital for
an unlimited period.
1
Two days before her death, the Holbolls uncharacteristically sought
hospital admission from Camden & Islington NHS Trust, because they
feared that
would harm his mother. As you can see from the
narrative attached, that admission was never effected.
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.
I heard evidence at inquest of a great many changes being implemented
by Camden & Islington since Ms Holboll’s death, and I have a copy of
your 17 point action plan.
I shall not rehearse those matters now, but I want simply to re-iterate the
overarching point that I discussed with your clinical director of acute
services.
It seemed to me from the evidence I heard that, when a need for good
communication (for example between clinician and bed manager) has
been identified, there has been a lack of precision in your trust about
exactly what that means and how it needs to be actioned.
Rather than simply talking about the need for better communication, it is
necessary to identify that information A must be delivered on every
occasion, by person B, at time C, and using method D. Without this level
of detail, staff are left with a vague concept and the communication is
unlikely to achieve the desired result.
I appreciate that this does not give you much in the way of specifics to
work on, but your organisation has already identified these. What I hope
to do is to share with you what I perceive to be a recurring theme in your
organisation, that has been particularly highlighted by Ms Holboll’s death.
6
ACTION SHOULD BE TAKEN
In my opinion, action should be taken to prevent future deaths and I
believe that you and your organisation 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 26 June 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
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
27.04.15
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.
Camden and Islington NHS Foundation Trust Executive office 4" Floor, East Wing St Pancras Hospital 4 St Pancras Way London NW1 OPE Tel: 020 3317 7016 Fax: 020 7561 4461 www.candi.nhs.uk 26" June 2015 Coroner ME Hassell Senior Coroner Inner North London St Pancras Coroner’s Court Camley Street London N1iC 4PP Dear Ms Hassell Re: Regulation 28 Prevention of Future Deaths report — Tamara Holboll (date of inquest 20 April 2015) | write in response to the Regulation 28 Prevention of Future Deaths report sent by you on 27 April 2015. You raised in your letter a concern about the lack of precision in our trust with respect to recommendations arising from Serious Incidents investigations on the need for good communication. Thank you for your very helpful comment and example of the clear format for the wording of actions to address the need for better communication. We have considered your recommendation carefully and we agree with you that we should improve the way we formulate our actions to ensure they achieve the desired result. We have an ongoing plan in place to review and improve our Serious Incidents processes; we are committed in particular to improving our ability to learn from incidents. Before | explain what actions we have taken to improve on this, it may be helpful to set out briefly the process of preparing and reviewing action plans arising from serious incident investigations. Serious incident investigations are usually allocated to an appropriately trained senior manager (Lead Investigator) from a Division other than the one where the incident occurred (the purpose of this is to achieve a level of objectivity); they are supported by a Clinical Expert from the Division where the incident occurred; this person is a specialist cont... Chair: Leisha Fullick Your partner in Chief Executive: Wendy Wallace care & improvement P29 C&l is an NHS Foundation Trust providing treatment and social care for mental ill-health FCamden ISLINGTON ™ nd substance misuse in adults in partnership with Camden and llington councils, NHS in the clinical area relevant for the investigation, but have not had direct involvement with the service user involved in the incident. The Lead Investigator and Clinical Expert prepare a report with recommendations following from their findings. Each serious incident investigation has an allocated Action Plan Manager, who is a senior manager in the Division where the incident occurred. The Action Plan Manager assists the investigators with preparing the action plan to ensure that the actions are in line with the workings of the service or appropriate to the Division. The Action Plan Manager also is also responsible for ensuring that the action plan is implemented. The action plan template is designed to prompt the author to allocate a responsible person for each action, a deadline for completion of each action and what evidence is required to confirm that the action has been completed (for example, if a policy needs revising the evidence will be a revised policy). Draft reports with action plan are reviewed by the Clinical Governance team, who may work further with the authors to ensure that the report and action plan comply with the Trust guidance included in the Serious Incident Investigation template. Finally, the report with action plan is approved and signed off by Executive Directors. The trust has taken the following actions to address the issue you have raised in your letter; some of these actions were started shortly before the inquest as part of our ongoing improvement plan for learning from serious incidents: 1. We have amended the action plan template and revised our guidance to authors writing recommendations and action plans. a) We have added an action row in the action plan table to prompt the authors to write an action arising from each respective recommendation. We find that recommendations are usually drafted in rather general and less concrete language, the prompt to produce and action based on the recommendations helps to remind the authors that specific, concrete action is required. Previous action plan template from former guidance: RECOMMENDATION AND) TIMESCALE EVIDENCE REQUIRED cont...
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