Prevention of Future Deaths reports · 2015

Masoud Ghaderi

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 report17 Jul 2015
Reference2015-0283
DeceasedMasoud Ghaderi
CoronerPeter Harrowing
Coroner areaAvon
CategoryHospital Death (Clinical Procedures and medical management) related deaths
Organisation namedAvon and Wiltshire Mental Health Partnership NHS Trust
Sourcejudiciary.uk record · original PDF
Responses published1

The report

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

Responses

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.

Response from Avon and Wiltshire NHS Trust (PDF)
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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