Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0293, written 21 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 | 21 Jul 2015 |
|---|---|
| Reference | 2015-0293 |
| Deceased | Anne Wilson |
| Coroner | Sonia Hayes |
| Coroner area | South London |
| Category | Community health care and emergency services related deaths |
| 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.
In the South London Coroners Court Inquest touching the death of Anne Wilson REGULATION 28: REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Sir Bernard Hogan-Howe, QPM. Commissioner of Police of the Metropolis 2. Dr Fionna Moore MBE, London Ambulance Service Chief Executive 1 | CORONER | am Sonia Hayes, assistant coroner, for the coroner area of South London 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 5" February 2015 the Senior Coroner commenced an investigation into the death of Anne Wilson, aged 59 years. The investigation concluded at the end of the inquest on g" July 2015. Miss Wilson admitted to some suicidal ideation during her admission to the Priory Hospital. She showed signs of improvement and was discharged with a care package. She failed to attend a scheduled appointment and a welfare call to the police on 2" February was downgraded. The conclusion of the inquest was Suicide, Miss Wilson was discovered deceased at her flat on 3rd February and the medical cause of death was hanging. 4 | CIRCUMSTANCES OF THE DEATH 1. Miss Wilson had a 10 year history of depression. In December 2014 she was admitted to the Priory Hospital with some suicidal ideation. She showed signs of improvement and was discharged on 29" January 2015 with a private care package. She had capacity and did not meet the criteria for assessment for detention under the Mental Health Act. 2. Miss Wilson did not attend an out-patient appointment on 30" January 2015 and she was contacted by her Consultant by telephone. Following lengthy discussion about her well-being, a further appointment was made for 2m February 2015. She did not attend and her Consultant was unsuccessful in her attempts to contact her that day. : 3. The Consultant contacted Miss Wilson's G.P that afternoon and raised her concerns. The G.P was also unsuccessful in attempts to contact Miss Wilson by telephone and a home visit. He telephoned the police at 16:29 raising his concerns for Miss Wilson's welfare and requesting forced entry. He gave a mobile telephone number upon which he could be contacted. The G.P was informed that the police would attend Miss Wilson's flat within the hour. 4. The MPS informed the LAS that the welfare request had been downgraded under their new policy and that they would not attend but did not inform the G.P. 5. The MPS did not pass on the G.P’s mobile telephone number to the LAS and the LAS experienced difficulty making contact with the G.P via his surgery. 6._The LAS contacted the MPS on 2™ February 2015 requesting the MPS to make South London Area Coroner’s Office, ST. Blaise Building, Bromley Civic Centre, Stockwell Close, Bromley, Kent BR1 3UH contact with the G.P. but this was not done. 7. The G.P contacted the police on 101 on the morning of 3" February 2015 for an update and to arrange any follow-up care if that was necessary. The G.P was informed that the police had not attended Miss Wilson's flat. The G.P escalated his concerns at 08:42 for Miss Wilson's safety via an emergency call to the police. 8. The MPS officers were immediately dispatched and Miss Wilson's was discovered deceased at 09:00 in her flat having hanged herself from the doorframe. 9. There were no reliable features to estimate the time or date of death. The evidence at inquest was that Miss Wilson's mobile telephone was turned off following calls from her doctors who had left voicemails on ane February and notes were found in her handwriting dated 2nd February. 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. — (1) In 2014 the Metropolitan Police Service (MPS) introduced a new policy for dealing with requests for and attending welfare checks. The precise date of the implementation of the new policy could not be established at inquest. The MPS and the London Ambulance Service (LAS) have joint working arrangements however the changes made concerning the future handling of welfare checks was not shared with the LAS at that time. (2) MPS staff responsible for dealing with requests for welfare checks were not given training in the new policy and the power-point guidance circulated did not contain: (a) A checklist or examples of questions that should be asked to elicit sufficient information about the concern being raised (b) an example of how to manage a request for a welfare check concerning the mental health of an individual (c) how to manage additional information received once a welfare check request had been closed. (d) The importance of updating those involved in the change in actions being taken by the MPS (3) The information provided by Miss Wilson's G.P to the MPS was available in full with those making the decision to downgrade the request for a welfare check: (a) Miss Wilson had suffered a relapse of severe depression (b) had just been discharged from psychiatric hospital (c) the welfare concern was raised by the discharging Consultant Psychiatrist and G.P (d) the G.P had specifically requested forced entry to Miss Wilson's property (4) The MPS call handler informed Miss Wilson’s G.P that the police would attend Miss Wilson's flat within the hour however the request for a welfare check was downgraded without informing the G.P of the change in decision or to seek South London Area Coroner’s Office, ST. Blaise Building, Bromley Civic Centre, Stockwell Close, Bromley, Kent BR1 3UH further clarification of his concerns. (5) The MPS did not share the G.P’s mobile telephone number with the LAS causing delay making further contact with the G.P. (6) It is unclear what version of the MPS Welfare Check policy in currently in force and a final version has not yet been shared with the LAS despite requests to do so. (7) The MPS and LAS have joint working arrangements but have yet to meet to discuss joint working arrangements under the MPS Welfare checks policy. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you and your organisations 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 15"" September 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. COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested — | have also sent it to the Mayor of London, of the Priory Hospital Hayes Grove a Park Practice who may find it useful or of interest. | have also sent it to the Mayor of London, who may find it useful or of interest. | 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. 21* July 2015 Sonia Hayes South London Area Coroner’s Office, ST. Blaise Building, Bromley Civic Centre, Stockwell Close, Bromley, Kent BR1 3UH
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.
15/89/2815 15:56 92077832009 LAS_LEGAL PAGE 22/
| 22/03
London Ambulance Service INHS|
NHS Trust
Ms Sonia Hayes Headquarters
Assistant Coroner 220 Waterloo Road
South London London
St Blaise Building SE1 88D
Bromley Civic Centre Tel: 020 7783 2000
Kent Fax: 020 7783 2265
BR1 3UH www. londgnambulante,nhs.uk
Date: 15" September 2015
Our ref : INQ/10538/14
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS arising from the Inquest
into the death of Anne Wilson
Dear Ms Hayes
Thank you for your Regulation 28 Report to prevent future deaths, dated 21st July 2015,
bringing to my attention the matters of concern:
6) It is unclear what version of the MPS Welfare Check policy is currently in force and a final
version has not been shared with the LAS daspite requests to do so.
7) The MPS and LAS have Joint working arrangements but have yet to meet to discuss joint
working arrangements under the LAS Welfare checks policy.
We have given careful consideration to the concerns raised and in this | have been advised
py the Trust's Director of Operations and Director of Nursing and Quality, as well as senior
managers in the Emergency Control Services about the actions to ensure that the learning °
from this tragic incident is embedded.
A copy of the Metropolitan Police ‘External Briefing Note — welfare checks dated March 2014
— updated March 2015 V.1" has been provided following the inquest. No fundamental
changes were identified with the previous version (March 2014 — updated December 2014
V.1). We understand the document updated in March 2015 to be the current version in force
and is to be incorporated into the LAS/MPS Joint Memorandum of Understanding by end
December 2015, in accordance with the annual review process. Nevertheless the Deputy
Director of Operations, Control Services and Deputy Director of Nursing and Quality will
discuss the policy and it’s impact for the LAS at the next quarterly meeting of the LAS / MPS
Joint Working Group on 13 November 2015.
The METDG Standard Operating Procedure “Procedure for the Assessment of Ambulance
Requests Received from the Metropolitan Police Service via CAD Link” v.5.0, issued on 18
February 2015, was provided as an attachment to the Serious Incident Investigation Report
STEIS 2015 — 5617 of 2 June 2015 which included guidance on the management of police
calls to high risk patient groups and no reply on ring back (paragraphs 6.1 and 6.2). The
guidance did not include the MPS welfare checks policy, and so as an interim measure and:
prior to the meeting on 13 November 2015, a Control Services Bulletin will be issued at the
15/89/2015 15:56 62077832009 LAS_LEGAL
- PAGE 63/83
end of September 2015 about the MPS welfare checks policy to mitigate the risk of a call to
a vulnerable patient being closed prior to assessment by a clinician.
Following this Regulation 28 Report, the Director of Operations, who is the Trust's strategic
operational lead for joint LAS and MPS working and the Director of Nursing and Quality, who
is responsible for strategic and policy liaison regarding mental health and safeguarding with.
the MPS, have asked for our joint mesting arrangements to be reviewed and clarified to
ensure that the governance arrangements are robust ard that the LAS is represented at an
appropriate level in the future.
{n closing | should like to offer my condolences to Anne’s family and to apologise for the
shortcomings that were identified in the in the Serious Incident Investigation Report dated 2.
June 2015, which was shared with you and Anne's family. | do hope too that this reply will be
helpful in explaining the action taken and being taken to address the matters of concern.
Yours sincgrely,
Dr Fionna Moore
Chief Executive London Ambulance Service NHS Trust
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