Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0283, written 17 Jul 2015. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 17 Jul 2015 |
|---|---|
| Reference | 2015-0283 |
| Deceased | Masoud Ghaderi |
| Coroner | Peter Harrowing |
| Coroner area | Avon |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Avon and Wiltshire Mental Health Partnership NHS 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 (1) NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 4. Avon and Wiltshire Mental Health Partnership NHS Trust 2, EEE widow of the Deceased 3. Care Quality Commission 4. Chief Coroner 1 | CORONER | am Dr. Peter Harrowing, LLM, Assistant Coroner, for the coroner 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 22nd April 2014 | commenced an investigation into the death of Mr. Masoud Ghaderi age 54 years. The investigation concluded at the end of the inquest on 11th June 2015. The conclusion of the jury was that the medical cause of death was \(a) Hanging and the conclusion as to the death was that of “Suicide. Insufficient communication, documentation and staffing led to inadequate overarching care, creating an environment in which Mr. Ghaderi was able to take his own life’. 4 | CIRCUMSTANCES OF THE DEATH From around August 2013 Mr. Ghaderi suffered from a depressive episode. He was initially treated by his general practitioner and prescribed antidepressants and then referred to a consultant psychiatrist. However, during November and December 2013 Mr. Ghaderi, who suffered with diabetes mellitus, took an overdose of insulin on three occasions on each of which he required hospital admission. Following the third overdose of insulin on 26th December 2013 Mr. Ghaderi was further assessed by the mental health team and on 31st December 2013 he was admitted as an informal patient to the Lime Unit, Callington Road Hospital, Bristol. HES Consultant Psychiatrist, told the Inquest that had Mr. Ghaderi not agreed to an informal admission to hospital or had later sought to leave the hospital without permission he would have been assessed under the Mental Health Act 1983 for formal admission. On admission Mr. Ghaderi was noted to be suffering with a severe depressive episode and his mood remained generally low throughout his admission. There was concern with regard to his risk of suicide although despite having constant suicidal thoughts Mr. Ghaderi denied any intention to act on those thoughts. However, on 11th February 2014 i the nursing staff questioned him with regard to a red mark around his neck. Mr. Ghaderi admitted he had tied his phone charger cord around his neck and said he did so to see what it was like. emained concerned with regard to her husband’s mental health particularly with regard to statements he made to her which she interpreted as being an indication of his suicidal intent. She told the Inquest that she had voiced those concerns to Zi’ and other members of staff on Lime Unit. On 3rd April 2014 Mr. Ghaderi underwent a session with fF [ Consultant Psychologist. During that session Mr. Ghaderi made reference to there being two weeks before everything would be resolved. EMBronsidered that he may have been referring to the resolution of financial matters which had continued to cause | him concern. However, Mr. Ghaderi left the session abruptly and avoided any questions with regard to any suicidal intent. As a os who had observed a marked change in Mr. Ghaderi’s mood and level of engagement, believed Mr. Ghaderi could have been referring to plans to take his own life. In evidence IEEE stated that she advised the nurse in charge of her concerns and the heightened risk of suicide. However, MM could not recall having that conversation with During the morning of 10th April 2014 EE vas carrying out routine observations and went to Mr. Ghaderi’s room at 11:06 hours. He had last been seen at 10:40 hours that morning on Lime Unit by Health Care Assistant looked through the observation window into the room and saw Mr. Ghaderi apparently standing and facing the door of his ensuite bathroom. She noted the bedroom light was off and the curtains were drawn. As she entered the room she discovered that Mr. Ghaderi was hanging by a belt from door of the bathroom. Assistance was immediately summoned and resuscitation attempted. The emergency services arrived shortly afterwards and Mr. Ghaderi was taken to the Bristol Royal Infirmary and he was admitted to the Intensive care Unit. Mr. Ghaderi did not recover and life support was withdrawn with the agreement of the family. He was pronounced dead at 13:47 hours on 12th April 2014. 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) There was inconsistence records of engagement with service users. The Engagement and Observation policy of the Trust should be reviewed to consider how the policy operates and how engagements with service users are to be recorded ina consistent manner with appropriate staff training in application of the policy. (2) There was no one member of staff with overarching responsibility for reviewing any risk assessments. Therefore any trends in changing risk, e.g. increasing risk of self-harm or suicide, could not be identified. The Trust should consider designating a member of staff with this responsibility in the same manner as it has one member of staff with responsibility for ensuring the care plan(s) are reviewed and maintained up-to-date. (3) The Trust has a comprehensive single care record for each service user. However, the ward rounds rely only on a brief summary prepared by a nurse the night before when that nurse may not have made any entries in the care record nor would be present at the ward round. The Trust should review its planning and preparation for ward rounds so that reliance is not placed solely on a brief summary with the inherent risk of errors and omissions . ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe your organisation has 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 10th September 2015. |, 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 [widow of the deceased, and the Care Quality Commission. | shall send a copy of your response toffEENENend the Care Quality Commission. | have sent a copy of my report to the Chief Coroner. lam 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. 17th July 20 Assistant Coroner
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.
Dr Peter Harrowing, LLM Assistant Coroner for Avon The Coroner’s Court Avon and Wiltshire NHS Mental Health Partnership NHS Trust Trust Headquarters Jenner House Langley Business Park The Courthouse Chippenham Old Weston Road SN15 1G6G - Bo, on hoa Tel: 01249 468023 ax jourton Email: Bristol BS48 1UL Our ref: 20150911/IT-N&Q 10 September 2015 Dear Dr Harrowing Response to Regulation 28 Report MG 11/9/15 In response to your concerns we would like to provide you with a summary of both actions already taken and those planned. 1. There was inconsistence record(s) of engagement with service users. The Engagement and Observation policy of the Trust should be reviewed to consider how the policy operates and how engagements with service users are to be recorded in a consistent manner with appropriate staff training in application of the policy. The Trust Engagement and Observation Policy is based on guidance in the recently revised Mental Health Act Code of Practice, (Chapter 26, Safe and Therapeutic Responses to Disturbed Behaviour). The Policy is also informed by the recently published NICE Guidance - Violence and aggression: short-term management in mental health, health and community settings, (NICE 2015). The Engagement and Observation policy is clear on what engagement is, what observation consists of and where and when these observations should be recorded. Please see extracts from policy below: 1. Introduction 1.1 Engagement and observation with a service user includes the reporting and recording of a service user's location, mental state, well-being and behaviour, which is central to the role of inpatient staff. Observation provides an opportunity for positive engagement with service users to assess and respond to their individual needs to aid their recovery. 1.2 Every inpatient who is receiving care and treatment is observed at some level as a necessary | part of their care. Where there are specific concerns, the service user may need to be placed on higher levels of observation for periods of time. 2. Policy Statement 2.1. | Engagement and observations are an integral part of a therapeutic plan. The service users care plan must specify the level of engagement and observation for them. Chair Trust Headquarters Chief Executive Anthony Gallagher Jenner House, Langley Park, Chippenham SN15 1GG lain Tulley 'We are a teaching, learning and research trust; we aim to inform you about relevant opportunities, unless you tell us otherwise.’ Sr al 2.5. Service users and their carers will be involved in the decision making and offered a clear rationale for the level of engagement and observation, unless their clinical presentation prevents this. This assessment, discussion and outcome will be clearly recorded. 2.8. Reductions in levels of observation may also be appropriate where it can be demonstrated that certain levels of observation are counter-therapeutic. In any such case the risks and rationale must be clearly documented. 5. Content 5.1. Assessment and Planning of Engagement and Observations 5.2. All service users admitted to an inpatient unit will have their risk assessment updated by the community team responsible, with a stated reason for admission and purpose of admission. A handover of care will be provided, which will inform the assessment of level of engagement and observation. The electronic record will be updated in alf occurrences. 5.8. The care plan will reflect any leave status / restrictions of a service user, the plan of care for undertaking observations when attending other therapeutic activities, i.e. whether to be escorted or not and who should undertake any escort, and when receiving visitors, with these decisions supported by a documented risk assessment. The monitoring of engagement and observation recording is through monthly management supervision. This is when the line manager sits with individual clinicians and goes through their caseload on the ward and highlights any issue or remedial actions to take. However, this has not been consistently monitored by the Clinical Executive; our plan is to undertake monthly spot audits of the caseload supervision records to ensure consistent application of the Engagement and Observation Policy: This audit will be taken to the Integrated Governance Group (IGG) meeting for action (attendees include Quality Directors from all localities). These audits will commence from October 2015. There are several Statutory and Mandatory Training Courses which cover the Engagement and Observation Policy; these are ‘Prevention and Management of Violence and Aggression (PMVA), ‘Violence and Aggression’ (Older Peoples Units); ‘Care Programme Approach’ (CPA). A new training package for Suicide Prevention is currently being designed. Local training in the implementation of the Trust Engagement and Observation Policy has been rolled out across all wards in Bristol following learning from root cause analysis process. During January to April 2015 the Trust carried out targeted training in inpatient suicide prevention. This included training in engagement and observation. The Trust plans to continue this targeted training between July and November 2015 and to include this as part of mandatory Care Programme Approach and Risk Training for inpatient staff from December 2015 onwards. 2. There was no one member of staff with overarching responsibility for reviewing any risk assessments. Therefore any trends in changing risk, e.g. increasing risk of self-harm or suicide could not be identified. The Trust should consider designating a member of staff with this responsibility in the same manner as it has one member of staff with responsibility for ensuring the care plans(s) are reviewed and maintained up-to-date. The Trust has in place processes and procedures for the co-ordinating of risk assessment information for inpatients. On day to day basis risk is constantly assessed and reviewed and changes to the care plan implemented accordingly, including reviews of engagement and observation levels, response to | treatment, leave and time away from the ward and activity involvement including occupational therapy. The Nurse in Charge is responsible for ensuring that any day to day changes in risk are responded to | appropriately, including involvement of the wider multi-disciplinary team where appropriate. Ward Teams are made up of a variety of members of the multi professional team including:Nurses, Doctors and Allied Health: Professionals.:A review: of care provided by the Multi Professional Team is undertaken on a weekly basis: The Trust operates a functional model for acute inpatient areas and therefore each ward has a designated Consultant. The Consultant is responsible for co-ordinating the weekly multi-disciplinary ward review and ensuring that the review considers information from all 6 professionals, and carers. The chair of this meeting should ensure that all changes in risk are considered and plans are reviewed and amended appropriately. This process encourages the identification of trends in changing risk. Staff performance against the expected standards of practice are reviewed through the Trust appraisal and supervision processes. The Clinical Executive appreciates the Coroners comments re responsibility for reviewing and as a result have commissioned an audit of reviewing risks across inpatient units. The Clinical Executive will take the information from this audit and design a framework of staff responsibilities for all staff to follow. 3. The Trust has a comprehensive single care record for each service users. However, the ward rounds rely only on a brief summary prepared by a nurse the night before when that nurse may not have made any entries in the care record nor would be present at the ward round, The Trust should review its planning and preparation for ward rounds so that reliance is not paced solely on a brief summary with the inherent risk of errors and omissions. When undertaking ward rounds, the care team have access to the patients full and comprehensive care record. However, it is accepted that there are occasions when the nursing summary is not as comprehensive as it should be. A full review of nursing models of care is to be undertaken by the Nursing Directorate with recommendations generated for a standardised model of care delivery (ie. named professional / team nursing structure). This will facilitate a more comprehensive recording of a patients presenting needs state at any given time. Also a review of the existing multi professional weekly review meetings has been undertaken. The findings and recommendations will be taken to the Integrated Governance Group, chaired by the Executive Director of Nursing and Quality in October 2015. The review was completed by the Heads of Quality for each of the six local delivery units. Yours sincerely miele | QD. cooals pp. | lain Tuliey Chief Executive
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