Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0172, written 1 May 2015. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 1 May 2015 |
|---|---|
| Reference | 2015-0172 |
| Deceased | Derrick Stanmore |
| Coroner | Lydia Brown |
| Coroner area | Leicester (City & South) |
| 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.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Dr Peter Miller, Chief Executive, Leicester Partnership Trust 1 | CORONER 1 am Lydia Brown, assistant coroner, for the coroner area of Leicester City and Leicestershire South 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 14 July 2014 | commenced an investigation into the death of Derick James Stanmore. The inquest concluded on 30 April 2015. The conclusion of the inquest was Natural causes Cause of death 1a Acute myocardial infarction 1b Coronary artery atheroma 4 | CIRCUMSTANCES OF THE DEATH Mr. Stanmore was serving a life sentence for murder and was at the time of his death in HMP Gartree. He had a number of recognised medical conditions, including cardiac disease and diabetes mellitus type II. He complained of chest pains on 7" July 2014, and there were 3 encounters with healthcare over the next 3 days, none of which made a potential diagnosis of cardiac problems and none of which resulted in a referral for review. On 10” July 2014 Mr. Stanmore collapsed in his cell and despite prompt and effective CPR and paramedic assistance, he was pronounced deceased shortly after his arrival at Kettering General Hospital. 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. — 1. Observations were taken on the morning of Mr, Stanmore's death by a registered nurse. The observations were abnormal and required further action to be taken but this was not recognised. A system similar to the hospital “Early Warning Score" (EWS) may assist the healthcare staff in recognising this and escalating care accordingly. 2. The nurse attending Mr. Stanmore did not access his healthcare records that were available and did not appear to have any information regarding the need for a healthcare assessment. He was therefore taking observations without the benefit of relevant clinical information in order to consider these in context. © | [DATE] Consideration should be given to ensu g all ave appropriate ac whenever possible to information before conducting examinations or observations of prisoners. | ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you have the power to take such action | 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. |, 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 Governor 0 artree. lam also sending a copy to, NHS England and the Prison and Probation Ombudsman as they may have an interest in this report | 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 (I< (eis
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.
Leicestershire Partnership
NHS Trust
From the Legal Affairs Department A University Teaching Trust
Direct dial: 0116 295 0920 Lakeside House
4 Smith Way
‘4 Grove Park
9" June 2015 Enderby
Leicester
LE19 1SS
re eae Tel: 0116 295 0030
M Coroner Fax: 0116 295 0842
Leicester City & South Leicester www.leicspt.nhs.uk
The Town Hall
Town Hall Square {—eicent
Leicester
LE1 9BG
Dear Mrs Brown,
Re. Derick James STANMORE
Further to your report dated 01 May 2015, in accordance with paragraph 7, Schedule 5 of
the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners
(Investigations) Regulations 2013, | offer the following response
We have investigated the matters that you have raised relating to concerns about members
of Leicestershire Partnership NHS Trust staff at HMYOI Glen Parva alleging issues
surrounding observations and access to health records.
Leicestershire Partnership NHS Trust takes these matters very seriously and | hope that you
and Mr Stanmore's family will be satisfied that we have taken the appropriate measures to
prevent such an occurrence happening again
ae :-.- Manager for Prison Healthcare in response to the Regulation 28 has
agreed to complete the following actions, as this covers the scope of your matter of concern:
1. Observations were taken on the morning of Mr. Stanmore's death by a
registered nurse. The observations were abnormal and required further action
to be taken, but this was not recognised. A system similar to the hospital
“Early Warning Score” (EWS) may assist the healthcare staff in recognising
this and escalating care accordingly.
The Healthcare Management / Clinical Leadership Team will be introducing an
adapted version of the Track and Trigger system as attached. Staff will need to be
trained in the use of this tool across our three Prison Healthcare Teams and we
anticipate that this will be in place by the 1 October 2015.
This will assist in ensuring that all healthcare staff are aware of the parameters of
physical observations and will be able to act swiftly in escalating any physical
observations that present with potential concerns. This system is used successfully
within the Community Hospitals that are managed under the care of Leicestershire
Partnership NHS Trust.
Chair: Professor David Chiddick CBE Chief Executive: Dr Peter Miller gt Mog,
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2. The nurse attending Mr. Stanmore did not access his healthcare records that
were available, and did not appear to have any information regarding the need
for a healthcare assessment. He was therefore taking observations without the
benefit of relevant clinical information in order to consider these in context.
Consideration should be given to ensuring all staff have appropriate access
whenever possible to information before conducting examinations or
observations of prisoners.
After review, | can confirm that all staff are able to access clinical information prior to
seeing Prisoners. Staff will be reminded that it is an expectation that when Prisoners
are seen routinely, clinical notes should be accessed in order to make a well
informed clinical decision.
Yours sincerely
Dr Peter Miller
Chief Executive
Attachment: Track and Trigger Form — to be adapted
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Chair: Professor David Chiddick CBE Chief Executive: Dr Peter Miller
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