Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0199, written 20 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 | 20 May 2015 |
|---|---|
| Reference | 2015-0199 |
| Deceased | Wanda Stachurska |
| Coroner | Bridget Dolan |
| Coroner area | West Sussex |
| Category | Suicide (from 2015) |
| Organisation named | Surrey and Borders Partnership NHS Foundation Trust |
| 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
THIS REPORT IS BEING SENT TO:
1, The Chief Executive, Surrey and Sussex Healthcare NHS Trust
2. The Chief Executive, Surrey and Borders Partnership NHS Foundation
Trust
CORONER
I am Bridget Dolan, assistant coroner, for the coroner area of West Sussex
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.
INVESTIGATION and INQUEST
On 25 November 2014 the Senior Coroner commenced an investigation into the death
of Mrs Wanda Stachurska The investigation concluded at the end of the inquest on 20
May 2015. The conclusion of the inquest was suicide, the medical cause of death being
hanging.
CIRCUMSTANCES OF THE DEATH
On 16 November 2014 Mrs Stachurska was brought by ambulance to the Emergency
Department (‘ED’) of East Surrey Hospital (managed by Surrey and Sussex Healthcare
NHS Trust ‘SASH’). She had been found that day by a member of the public having
taken an overdose of 30 sleeping tablets and was attempting to hang herself from a
bridge. She was also hypothermic from immersing herself in the cold water of a brook.
She informed the ambulance crew that she had been “trying to commit suicide”.
Mrs Stachurska stayed overnight in the hospital and the following morning she again
expressed “suicidal intent” to the ED consultant. At around 17.00 hours that afternoon
she was assessed in the ED by mental health nurse from Surrey and Borders Partnership
NHS Foundation Trust (SABP”’). That nurse noted Mrs Stachurska now denied suicidal
feelings. She considered that there was a low risk of self harm and hence Mrs Stachurska
was discharged home at around 19.00 hours. The nurse did not ascertain that Mrs
Stachurska had attempted to self-ligature at the bridge the previous day, although this
information had been handed over orally by the ambulance staff to the ED triage nurse.
The mental health nurse stated that had she known this information it would have been
relevant to her risk assessment.
Mrs Stachurska was discovered deceased at around 09.00 the following morning, 18
November 2014, having hanged herself from a tree in a park not far from her home.
Mrs Stachurska was Polish and had limited command of English, hence her assessment
by the mental health nurse had to be facilitated through an interpreter. The nurse
considered it was important to observe the patient’s interaction and non-verbal cues
through a face-to-face interpreter. | The relevant SASH policy was “to only use
interpreters who are bilingually competent, neutral, independent and_ professionally
trained and qualified” and that “the use of staff is not acceptable unless there are
exceptional circumstances” (eg emergency situations). The mental health nurse stated
that this was not an emergency situation. She also stated that she was not aware of the
SASH policy as although she was based at the East Surrey Hospital, where she
understood SASH policies would apply, she was not required to be familiar with SASH
policies because she was an employee of SABP.
‘The interpreter who was then provided to her by SASH was a Polish man who was
employed by a sub-contractor and worked as a security guard at the hospital. The nurse’s
experience was that the provision of a staff member as a face-to-face interpreter was the
norm rather than an exceptional occurrence.
It appeared from the nurse’s account that the provision of the security guard as an
interpreter was sub-optimal in that, although he endeavoured to assist, he did not always
directly translate but rather reported a theme of what was being said. Her view was that
using a professional interpreter may have improved the quality of her assessment and
allowed her to gain more understanding of the nuances of what the patient was saying.
Additionally, she stated that if an interpreter had been provided to her who was at least a
health care professional this would have been better, because that person would have
had more understanding of terms and terminology and the reasons for the assessment.
She had in the past completed mental health assessments using members of clinical staff
which she had found preferable. | Furthermore, it was apparent that the security guard
later discussed some information about the patient with another person. It should be
noted that although he had been asked by SASH to act as a translator for Polish patients
on several other occasions the man had not been given any training or guidance by
SASH in respect of how he should carry out this role and the nurse said that he had not
been informed about clinical confidentiality in respect of this particular assessment.
No serious incident report or review of this death has been conducted by either Trust
involved. The mental health nurse had learned of the death from her line manager who
she considered was responsible for reporting the incident and could give no explanation
why this ‘grade 1” serious incident under the SABP policy had not been the subject of a
SABP SI review. | The ED consultant was of the opinion that a serious incident review
was not required under the SASH policy because he believed there had been no
omissions or shortcomings in the clinical care provided by SASH.
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
citcumstances it is my statutory duty to report to you.
The MATTERS OF CONCERN are as follows. —
(1) That the quality of the mental health risk assessment may be diminished if:
(a) Mental health staff are not aware of relevant SASH policies when working at
East Surrey Hospital;
(b) the use of untrained staff as interpreters for mental health assessments is the
norm rather than an exceptional or emergency occurrence;
(c) staff members who are not health care professionals are asked to interpret during
mental health assessments;
(d) Staff members who are asked to interpret during mental health assessments are
not given any training or guidance as to how to carry out this tole.
(2) Neither SASH nor SABP had considered that they should undertake a serious
incident review into the case despite the death of a patient only a few hours after
discharge.
(a) An opportunity to learn lessons from the above events has hence been delayed
and potentially been lost;
(b) To decline to conduct a serious incident review because of a pre-determined
opinion that there had been not been any omissions or shortcomings by the
organisation might reflect a misunderstanding by SASH of the purpose and value
of such investigations.
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe your
organisations 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 16 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 following Interested
Persons {EES [have also sent it to SECAMB, who may
find it useful or of interest.
Iam 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
20 May 2015 € Bridget Dolan
eeESY: _f pet ’o:
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.
Surrey and Borders Partnership NHS) NHS Foundation Trust Quality Directorate Trust HQ th 15" July 2015 18 Mole Business Park Randalls Road Leatherhead Bridget Dolan Sure KT22 7AD Assistant Coroner Le Coroner's Office Email: fr SY Wester Sussex Record Office Orchard Street Chichester West Sussex PO19 1DD Dear Mrs Dolan Inquest into the death of Wanda Stachurska - REGULATION 28 REPORT TO PREVENT FUTURE DEATHS Further to the conclusion of the inquest into Mrs Stachurska’s death on 17 November 2014, you wrote to Surrey and Borders Partnership NHS Foundation Trust in accordance with the Regulation 28 report to prevent future deaths, stating that during the course of the inquest the evidence revealed matters giving rise to concern. We would like to take this opportunity to offer our sincere condolences to Mrs Stachurska’s family for their loss. The areas of concern you raised that relate to our Trust and our responses are detailed below: 1.That the quality of the mental health risk assessment may be diminished if: (a) mental health staff are not aware of relevant SASH policies when working at East Surrey Hospital; (b) the use of untrained staff as interpreters for mental health assessments is the norm rather than an exceptional or emergency occurrence; (c) staff members who are not health care professionals are asked to interpret during mental health assessments are not given any training or guidance as to how to carry out this role. 1a) We have worked with our colleagues at East Surrey Hospital to ensure that a shortcut to Surrey and Sussex Hospital (SASH) policies is loaded onto all of our Psychiatric Liaison staff's computers to ensure ease of access for our staff. The SASH policy relating to using translation services has been made available as mandatory reading for our staff working at SASH. 1b) As a local protocol, we have now mandated that where possible two staff will undertake an assessment when the use of a Translator is required, and full discussion between the staff will take place prior to a discharge plan being Surrey and Borders Partnership INHS| NHS Foundation Trust confirmed. It is hoped that this will reduce any cultural misunderstanding and aid in better interpretation of the information. 1c) In SASH's procedures it is outlined that a member of staff can be used as the interpreter in an emergency situation. However when using a member of staff as an interpreter, Psychiatric Liaison Services will ensure that this member of staff must be a healthcare professional and is aware of their accountability, responsibility and confidentiality duties. We have reminded our staff to ensure that they record clearly in our electronic patient records any decisions made regarding the use of an interpreter and outline the rational for using staff for this role. It has also been mandated that staff check that any use of an interpreting service is adhering to the East Surrey Hospital interpreter and translator policy and that they record in the patient records their compliance to this policy for that interaction. 2. Neither SASH nor SABP had considered that they should undertake a serious incident review into the case despite the death of a patient only a few hours after discharge. (a) An opportunity to learn lessons from the above events has hence been delayed and potentially been lost; We agree that an opportunity for prompt learning has been lost due to the delay in investigation. We however want to stress that we do take learning from such events seriously and as such we will be following up with the team concerned to ensure that the actions that have been agreed are embedded in practice, to prevent any future adverse events. In this instance at the time of the incident coming to light, we believed that the lead provider in the care at the time of the death was going to report and lead the investigation process and as due process we would have taken part in the investigation. Unfortunately in this instance all the communication regarding the responsibility for the serious incident investigation was managed through the HM Coroner's Office instead of directly with our acute care provider colleagues as per our general practice. We have taken steps to ensure that when such issues arise we as providers make contact with each other early and agree reporting and investigation responsibilities. Our Board and commissioners will be made aware of your letter and the actions we have taken to strengthen our processes going forward. We hope that the steps we have taken as outlined above assure you and Mrs Stachurska’s family that we have learnt and continue to learn from Mrs Stachurska’s death. Please do not hesitate to contact me if you require any further information. Yours sincerely Director of Quality and Deputy Chief Executive (Nurse Director) cc Surrey and Borders Partnership [i'/e £9 NHS Foundation Trust Fiona Edwards, Chief Executive Medical Director Ge Director of Children & Young People Services GE Director Risk & Safety (DDoN)
See every Prevention of Future Deaths report matching Surrey and Borders Partnership NHS Foundation Trust, 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.