Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0205, written 29 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 | 29 May 2015 |
|---|---|
| Reference | 2015-0205 |
| Deceased | Alison Draper |
| Coroner | Maria Voisin |
| Coroner area | Avon |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
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 (1)
NOTE: This form is to be used after an inquest.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
1. lain Tulley
Chief Executive
Avon & Wiltshire NHS Partnership Trust
1 | CORONER
| am Maria Voisin, Senior Coroner, for the Area of Avon
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 10'" September 2014 an investigation into the death of Alison Jane DRAPER, Aged
45 commenced. The investigation concluded at the end of the inquest on 28" May 2015.
The conclusion of the inquest was:
Medical Cause of Death
la Hypoxic brain injury
Ib Neck ligature
Ic Mental health issues
Conclusion — Narrative
Alison Draper was found ligatured in her bedroom whilst a patient on Juniper Ward, she
died from the injuries she sustained, her intention is unknown. She was on 10 minute
observations at the time and should have been checked at 7pm she was not found in
her bedroom until approximately 7.12pm which was 20 minutes approximately from the
previous check; this resulted in a lost opportunity to render medical care, attention or
treatment.
4 | CIRCUMSTANCES OF THE DEATH
Ms. Draper had a history of mental health problems over a number years which included
several attempts to self-harm and take her life.
On 8" August 2014 she was admitted to Elizabeth Casson House at Callington Road
Hospital, she was detained under Section 2 of the Mental Heaith Act.
During this admission she made 8 attempts to take her life by ligature. The risk of self-
harm/suicide was described by her Consultant. Jas being chronic and
impulsive.
On 5" September 2014 Ms. Draper was stepped down from the Psychiatric Intensive
Care unit to Juniper Ward (an open acute unit).
On 7" September a Health Care Assistant was tasked with carrying out 10 minutes
observations on Ms. Draper. She last observed her at 18:50 in the garden.
At the 7pm check the same Health Care Assistant was also tasked with carrying out the
hourly checks for all 19 patients on the ward, two of whom were on 10 minute
observations, one of whom was Ms. Draper.
It is unclear how the checks were actually carried out as the witness could not remember
but at approximately 7:10/7:12 pm she asked for assistance from two other members of
staff. Ms Draper was found in her own bedroom having ligatured herself.
Ms. Draper was taken to Hospital but suffered an un-survivable hypoxic brain injury
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. —
4. | heard evidence that there is no policy in relation to what staff should do if a
patient/service user is not found within the 10 minute observation period. | would
ask that you consider whether guidance should be issued as to the steps that
staff should take.
2. {would also request that you consider the hourly check as detailed above. It
appears in this case that one member of staff was asked to check 19 patients,
two of whom were on 10 minute observations. Please consider whether
guidance be given as to how to manage and balance the hourly checks with
those on 10 minute observations.
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" July 2045. |, 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 legal representatives of
the family.
| 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.
29™ May 2015 M. E. Voisin
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