Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0208, written 1 Jun 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 Jun 2015 |
|---|---|
| Reference | 2015-0208 |
| Deceased | Mark Daniels |
| Coroner | Mary Hassell |
| Coroner area | Inner North London |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| 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: Prevention of Future Deaths report
Mark Patrick DANIELS (died 27.11.14)
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
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.
3
INVESTIGATION and INQUEST
On 3 December 2014, I commenced an investigation into the death of
Mark Daniels, aged 56 years. The investigation concluded at the end of
the inquest earlier today. I made a narrative determination, which I
attach.
4
CIRCUMSTANCES OF THE DEATH
Mr Daniels hanged himself following several contacts with South Camden
Crisis Response and Resolution Team. There was an agreement that he
be admitted to Rivers Crisis House, but this never took place.
1
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.
You will see from the determination attached, that I found there was a
failure by the crisis team:
-
-
-
-
-
to visit Mr Daniels twice a day, despite a plan so to do;
to record why twice daily visits were not attempted;
to communicate within the team and with the two crisis houses;
to progress the referral to a crisis house promptly;
to consider hospital admission, despite the fact that Mr Daniels
was known to have made several suicide attempts; had told staff
he did not feel safe at home; was observed to be keeping a rope at
home; told staff he would kill himself, albeit not immediately; said
he wanted to be in a contained environment; and there was
apparently no prospect of prompt admission to crisis house.
I gained the impression of a lack of cohesion and clinical direction.
6
ACTION SHOULD BE TAKEN
In my opinion, action should be taken to prevent future deaths and I
believe that you and your organisation 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 31 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 following.
2
HHJ Peter Thornton QC, the Chief Coroner of England & Wales
Care Quality Commission for England
Professor Dame Sally Davies, Chief Medical Officer for England
, sister of Mark Daniels.
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
interest. You may make
he believes may
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
1 June 2015
3
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.
a) b) c) d) Camden and Islington INHS| NHS Foundation Trust Executive office 4" Floor, East Wing St Pancras Hospital 4 St Pancras Way London NW1 OPE Tel: Fax; www.candi.nhs.uk 30 July 2015 Coroner ME Hassell Senior Coroner Inner North London St Pancras Coroner’s Court Camley Street London N1C 4PP Dear Senior Coroner Hassell Re: Mr Mark Patrick Daniels (deceased) | write further to your report on the above dated 1 June 2015 in which you highlighted concerns about the care delivered by the Trust to Mr Daniels. | 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 Daniels you noted the following failures by the Crisis team: to visit Mr Daniels twice a day despite a plan to do so; to record why twice daily visits were not attempted; to communicate within the team and with the two Crisis houses; to consider hospital admission despite the fact that Mr Daniels was known to have made several suicide attempts; had told staff he did not feel safe at home; was observed to be keeping a rope at home; told staff he would kill himself, albeit not immediately; said he wanted to be in a contained environment; and there was apparently no prospect of a prompt admission to a Crisis house. HR Associate Divisional Director for the Acute division has considered your concerns and put in place a comprehensive action plan to address them — the action plan is appended at the end of this letter. As you can see from the action plan updates, several Chair: Leisha Fullick Your partner in CRI Chief Executive: Wendy Wallace care & improvement Py C&l is an NHS Foundation Trust providing treatment and social care for mental ill-health ZSCamden # ISLINGTON and substance misuse in adults in partnership with Camden and Islington councils. NHS) measures have been put in place across all the Crisis Teams and the Crisis Houses in the Trust to address the concerns you have raised and there is a plan to monitor the implementation of these measures. | 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
See every Prevention of Future Deaths report matching Hospital Death (Clinical Procedures and medical management) related deaths, 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.