Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0173, written 29 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 | 29 Apr 2015 |
|---|---|
| Reference | 2015-0173 |
| Deceased | Finnulla Martin |
| Coroner | Mary Hassell |
| Coroner area | Inner North London |
| Category | Suicide (from 2015) |
| Organisation named | Camden and Islington NHS Foundation Trust · Whittington Hospital NHS Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Regulation 28: Prevention of Future Deaths report
Finnulla Catherine MARTIN (died 16.11.14)
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
2. Mr Simon Pleydell
Chief Executive
The Whittington Hospital NHS Trust
Magdala Avenue
London N19 5NF
3. Detective Chief Superintendent
Islington Borough Commander
Metropolitan Police Service
2 Tolpuddle Street
London N1 0YY
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.
1
3
INVESTIGATION and INQUEST
On 19 November 2014, I commenced an investigation into the death of
Finnulla Catherine Martin, aged 35 years. The investigation concluded at
the end of the inquest today. I made a narrative determination, which I
attach to this letter.
4
CIRCUMSTANCES OF THE DEATH
Ms Martin took her own life by jumping from the sixth floor balcony of her
home, less than an hour after she had been discharged from the
Whittington Hospital where she had undergone a mental health
assessment.
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.
I am conscious that some matters are already being addressed, but I
think it would nevertheless be helpful to set out my concerns below.
The MATTERS OF CONCERN are as follows.
Camden and Islington Trust
1. It seemed from the evidence I heard that the Camden and Islington
Trust psychiatry liaison team (doctor and nurse) operating at
Whittington Hospital on the night of 15 November 2015, were not
wholly clear about the protocols for receipt of information from
police officers bringing patients into hospital on a voluntary basis.
2. The team then saw a patient without waiting to obtain the triage
record created by Whittington Hospital Trust staff.
3. The doctor did not ask Ms Martin about thoughts of suicide within
the context of her earlier declaration that she would die that night.
4. He did not ask her about any thoughts of harming another person,
regardless of the fact he was not aware that she had threatened
this.
5. He did not address his mind to what had led up to the police being
called for Ms Martin, nor who had called them.
2
6. Neither doctor nor nurse obtained a collateral history of events
from a family member before concluding their interview with Ms
Martin.
7. When they obtained this afterwards and then realised that Ms
Martin had left the hospital, they contacted the police but did not
characterise this as an emergency.
8. The crisis team did not pass on information received from Ms
Martin’s sister to the psychiatry liaison team with a sufficient
degree of urgency to ensure that this was taken into consideration
before the interview with Ms Martin was concluded.
Whittington Hospital Trust
1. There seemed to be some degree of confusion surrounding the
voluntary attendance of a patient with mental health needs
accompanied by
that suggests a multi agency
discussion and agreement would be beneficial.
the police,
2. I was told at inquest by Camden & Islington that the Whittington
had been unable to locate the Whittington triage record of Ms
Martin’s attendance, and I did not discover any record of the call
made by Ms Martin’s sister to the emergency department that
night.
Metropolitan Police Service
1. The police call handler who spoke to Ms Martin did not record that
she said: “I need to jump a balcony”. This was important
information.
2. As I have indicated above, the confusion surrounding voluntary
attendance of a patient with mental health needs accompanied by
the police, suggests a multi agency discussion and agreement
would be beneficial.
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.
3
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
Professor Dame Sally Davies, Chief Medical Officer for England
Messrs Kevin & Paul Martin, siblings
, mother of Finnulla Martin
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
29.04.15
4
Whittington Health INHS
Dr Richard Jennings
Executive Medical Director
Whittington Health
Jenner Building
Magdala Avenue
London
N19 5NF
24" June 2015
Private and Confidential
HM Coroner Mary Hassell
HM Coroner’s Office
St Pancras
Camley Street
London N1C 4PP
Dear Ms Hassell
Re: Finnulla Catherine MARTIN inquest
Further to the Finnulla Martin inquest held on the 28" April 2015 and the PFD report dated
29" April 2015. Please find enclosed the trust's response by way of an action plan.
Should you require any further information, please do not hesitate to contact me.
Yours Sincerely
Executive Medical Director
Established as The Whittington Hospital NHS Trust
Chairman: Mr Steve Hitchins Chief Executive: Mr Simon Pleydell
Whittington Health NHS|
; Regulation 28: Prevention of Future Deaths
Action plan following the report of:
Coroner ME Hassell
Senior Coroner
Inner North London
St Pancras Coroner's Court
Camley Street
London N1C 4PP
Into the death of:
Finnulla Catherine MARTIN (date of death 16.11.14)
Identified MATTERS OF CONCERN for Whittington Health:
1. There seemed to be some degree of confusion surrounding the voluntary attendance of a patient with mental health needs accompanied by the police, that
suggests a multi-agency discussion and agreement would be beneficial.
Recommendation Key Action(s) Completion Date Responsible Progress on actions and {| Evidence of
Lead(s) dates: implementation and
date of implementation
Multi-agency discussion a) Development of care Guidelines to be a) June 2015-—On_ | The set of guidelines
and agreement guidelines relating to signed off at August track. The police
patients brought into the 2015 ED Board and | Consultant in guidelines have _| (draft v3 attached)
Emergency Department by | all other actions to Emergency been drafted and The completed
the police. be completed by Medicine shared with Performa (see
01/08/15 | | mental health attached)
To implement use of a ; . Trust. Version 3
mental health Proforma to Professional in progress Minutes and action
improve the quality of development (attached). To be | notes from Operational
; Whittington Health NHS'
assessments and ensure reviewed at next | meetings and ED
this is available to mental operational Board.
health colleagues | | meeting
AD Acute (09/07/15)
vais Services
The guidelines to be ; Proforma has
agreed by Whittington been developed
Health, Camden and and being piloted
Islington FT and (attached)
Metropolitan Police
Services in local boroughs Senior police
of Haringey and Islington. colleagues from
Islington have
attended ED
Board May 18",
Planning to invite
Haringey in July
TBC ,
To develop a new operational June 2015 p Meeting terms of Terms of reference
group between Whittington Health ACUIS reference agreed (attached)
and Camden & Islington Mental Services (WH) | _ . , ;
Health Trust to improve First meeting held Minutes from meetings
communication, operational a 11/6/15
processes and oversee
governance. To invite police
representation as require
Operational
Manager
(CIFT)
2. Coroner Hassell was told at the inquest by Camden & Islington that the Whittington has been unable to locate the Whittington triage record of Ms Martin’s
Whittington Health (WG
attendance, and did not discover any record of the call made by Ms Martin's sister to the emergency department that night.
Whittington Health response — all triage assessments are recorded electronically. Patient FM was triaged. Arrived with police at 21:00 and was assessed
and triaged at 21:15:
Pt brought in by police c/o suicidal ideations. Family concerned about patient. Patient voluntary. pmh: unknown.
National Triage category — mental illness — category 2 very urgent- discriminator — high risk of self-harm
Recommendation
For all Camden and
Islington Foundation
Trust employees and
associated locum staff to
have good
understanding of the
Emergency Department
computer system
‘Medway’ to improve
information available to
them
Recording of calls made
to the Emergency
Department
Provide written guide on use of
Emergency Department computer
system
To repeat training on the Medway
system
To review progress at operational
meetings
To agree and develop a risk
assessment tool to identify calls
that requires action and those that
do not.
To agree a local standard
operating procedure
Completion Date
End of July 2015
August 2015
Responsible
Lead(s)
AD Acute
Services
Clinical Lead
& Consultant
in Emergency
Care
Progress on actions and
dates:
Agree which aspects of
Medway system CIFT
staff will use —
completed
User guide for CIFT staff
under development —
draft attached
This action is to be
discussed at ED
Operational Board
Evidence of
implementation and
date of implementation
The written guide
(attached)
Training log
The risk tool
Formulation of
standard operating
procedure
Whittington Health (19
Undertake staff training on the tool
and complete audit to review the
impact
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