Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0184, written 11 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 | 11 May 2015 |
|---|---|
| Reference | 2015-0184 |
| Deceased | Keith Gallimore |
| Coroner | R Brittain |
| 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: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: (1) Wendy Wallace, Chief Executive, Camden and Islington NHS Foundation Trust (CANDI) 1 CORONER I am R Brittain, Assistant Coroner for Inner North London 2 CORONER’S LEGAL POWERS I 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 Keith Gallimore died on 4 December 2014, aged 30. The medical cause of death was the combined toxic effects of heroin and cocaine. The inquest into his death was heard on 1 May 2015, at which I recorded an open conclusion. It was not possible to establish suicidal intent to the necessary standard of proof, nor was it possible to determine that the death was accidental. 4 CIRCUMSTANCES OF THE DEATH Mr Gallimore had a background history of complications following appendicectomy, along with significant psychological stressors, related to his social situation. This resulted in him attending his General Practitioner, in order to seek help for anxiety and depression. He was referred to the ‘iCope’ service provided by CANDI and consulted with a clinical psychologist in November 2014. Mr Gallimore discussed plans he had made for committing suicide at this consultation, which prompted referral to the ‘Crisis Team’ within the same Mental Health Trust. A referral note was made in the ‘Rio’ electronic medical records which could be accessed by both iCope and the Crisis Team. This set out a summary of the psychologist’s consultation, which was fully documented in iCope’s own electronic record system. This system was not accessible by the Crisis Team but a request could be made to iCope for the full documentation to be copied into the Rio records. I heard evidence from the clinical lead of iCope that he was unclear as to why their records were not accessible by others within CANDI but considered that there may be issues regarding the potentially sensitive nature of these notes. He also set out his expectation that notes made by iCope should be duplicated in the Rio notes. A member of the Crisis Team reviewed Mr Gallimore a day after the referral was made, at which time he did not report any ongoing plans for suicide, nor was he thought to have a 1 mental health diagnosis. He was discharged from the Crisis Team at this point (with ongoing plans having already been made for followup within CANDI). Unfortunately, he was found deceased at his home address on 4 December 2014. 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) I am concerned that potentially important information, documented by a service provided by CANDI, is not accessible by other services within the same Trust, without a proactive request being made. It was not clear why this restriction is in place, nor what steps could be taken if information was required in an ‘outofhours’ setting, at which time the iCope service would not be available to copy notes to Rio. Although there was no evidence that, had the iCope notes been available to the Crisis Team, the outcome of Mr Gallimore’s case would have been different, I am concerned that future deaths could result because of this issue. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe that the addressee, has 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 6 July 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 Chief Coroner and to the Gallimore family. 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 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 11 May 2015 Assistant Coroner R Brittain 2
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 INHS 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 17 July 2015 Assistant Coroner R Brittain Inner North London St Pancras Coroner’s Court Camley Street London N1C 4PP Dear Assistant Coroner R Brittain Re: Mr Keith Gallimore | write further to your report on the above dated 11°" May 2015 in which you highlighted concerns about the care delivered by the Trust to Mr Gallimore. Thank you for agreeing to extend the deadline for this response by 20 July. | wish to thank you for bringing your concerns to our attention and | am writing to address the issues you have raised and give assurance that we have taken action to prevent future occurrences. Following the inquest into the death of Mr Gallimore you made the following observation in logging a PFD. ‘Potentially important information, documented by a service provided by CANDI, is not accessible to other services within the same Trust, without a proactive request being made. It was not clear why this restriction is in place, nor what steps could be taken if the information was required in an out of hours setting, at which point ICOPE would not be available to copy notes to RIO. Although there was no evidence that, had the ICOPE notes been available to the Crisis Team , the outcome of Mr Gallimore’s case would have been different, | am concerned that future deaths could result because of this issue.’ | agree that there is a gap in information sharing between ICope and rest of the Trust, this is because of the use of different electronic patient record systems. ICope is obliged to use electronic patient records system called IAPTUS because of national data reporting requirements, whilst all other services in the Trust use electronic patient records system called RIO. ICope has an established protocol for checking all new referrals against the RIO system and for making entries on RIO where patients have either current or recent contact with the service. Chair: Leisha Fullick Your partner in CRI Chief Executive: Wendy Wallace care & improvement a4 C&l is an NHS Foundation Trust providing treatment and social care for mental ill-health S2Camden @ ISLINGTON and substance misuse in adults in parinensAl with Camden and Islington councils. Camden and Islington INHS NHS Foundation Trust However, the problem arises when a patient presents to secondary care services (these use RiO) for the first time. There is no way of staff identifying if they are a current or past user of Cope, and even if the patient advises them that they have been attending ICope, there is no way of accessing the relevant information directly. This would require a call to the ICope services and, if this occurs out of hours, there will be no staff in ICope to provide the information. This is of particular concern for the Trust Crisis teams. One possible solution would be for all ICope staff to enter all their patient data on RIO as well as IAPTUS. Given the number of referrals to the service (some 17,000 in the last year) this is impractical and would mostly be of little benefit. Following discussion between leads in our Acute Division and ICope it was agreed that the most effective solution would be to provide IAPTUS training to a small number of front-line staff (who provide services 7 days a week/ 24 hours a day) in the Acute Division. This means that staff working in the acute assessment teams will able to make routine checks on all new patients against the IAPTUS system and have immediate access to the full clinical notes. All IAPT staff are already trained on the use of RiO electronic system and have access to RiO. As the Trust changes to different electronic records system Carenotes in September 2015 all IAPT staff will be trained to use Carenotes. We have identified the teams in the Acute and staff within those teams who will receive IAPTUS training; the teams are: Psychiatry Liaison Teams at the Royal Free Hospital, the Whittington Hospital and the University College London Hospital; Islington and North and South Camden Crisis Resolution Teams, and the Bed Management team. We have agreed with our contractor for the provision of training, which will take place at the end of September. | hope you are satisfied that we have taken action to address the concern which you have very helpfully raised. Yours sincerely, endy Wallace Chief Executive Chair: Leisha Fullick Your partner in Chief Executive: Wendy Wallace care & improvement Pa 4 C&l is an NHS Foundation Trust providing treatment and social care for mental ill-health ZECamden ISLINGTON and substance misuse in adults in partnership with Camden and Islington councils.
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