Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0296, written 24 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 | 24 Jul 2015 |
|---|---|
| Reference | 2015-0296 |
| Deceased | Simon Reynolds |
| Coroner | Maria Voisin |
| Coroner area | Avon |
| Category | Mental Health related deaths |
| Organisation named | Avon and Wiltshire Mental Health Partnership NHS Trust |
| 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 Mental Health NHS Trust Jenner House Langley Park Estate Chippenham Wiltshire SN15 1GG CORONER lam M. E. Voisin, Senior Coroner, for the Area of Avon 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. INVESTIGATION and INQUEST On 2™ December 2014 | commenced an investigation into the death of Simon Peter REYNOLDS, aged 47. The investigation concluded at the end of the inquest on 15" July 2015. The medical cause of death reached following a Jury inquest was as follows: 1a) Acute pneumonia 1b) Cachexia and chronic obstructive pulmonary disease. The conclusion of the Jury inquest was “The conclusion of this jury is that as a consequence of choking on paper which led to cardiac arrest, Simon subsequently died due to acute pneumonia, cachexia and chronic obstructive pulmonary disease” CIRCUMSTANCES OF THE DEATH On 10" November 2014 Simon was admitted to Mason Unit at Southmead Hospital after he was detained under $136 of the Mental Health Act by the police. He was admitted to the unit at around 21:00 hours and by 21:20 hours he was found by the staff in the bathroom with his hand over his mouth and he appeared to be choking. He was taken to the Intensive Care Unit at Southmead Hospital but died on 21°' November. Evidence was given that Simon was experiencing a psychotic episode with comments such as “he had bought the devils stone and lost” and that he thought “he was on a route to hell”. There were times when Simon appeared to be fighting hallucinations. One of the police officers who escorted him to the unit and was present with him said that Simon honestly believed what he was saying he was completely distressed. During his admission he attempted to stab himself in the neck with a pen, which the staff then removed. He also had his shoes and laces removed when he told the staff he wanted to die and they had concerns about self-harm/suicide. Whilst left alone in his room Simon forced a fist sized ball of paper into his throat which caused him to choke. During his short admission he was on 10 minute observations. 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) [heard evidence that there is no documented risk assessment produced at the time of a service user's admission onto Mason Unit. | would ask that you review whether this is still appropriate. (2) During the investigation | heard evidence that the nurse in charge made no record on the computerised Rio notes in relation to the admission. | would ask that you look into the appropriateness of this. (3) | would also ask that you consider whether guidance or training ought to be provided to staff on how to set patient observation levels when being admitted onto Mason Unit; what factors to take into account when assessing a service users risk of suicide or self-harm and how to manage that risk appropriately and how to appropriately communicate that risk to other staff. 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 21°t 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 the Chief Coroner and to the following Interested Persons — the family - and to the local safeguarding adult's board. | 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. 24 July 2015 M. E. Voisin j,t—“(tsCtsr a
Avon and Wiltshire INHS| Mental Health Partnership:-NHS Trust Maria Voisin Chief Executive’s Office Senior Coroner Jenner House The Coroner’s Court Langley Park The Courthouse Chippenham Old Weston Road Wiltshire Flax Bourton SN15 1GG BS48 1UL 01249 468023 18 September 2015 Dear Ms Voisin Simon Peter Reynolds deceased | am writing to respond to the concerns you raised in your Regulation 28: Report to Prevent Future Deaths relating to Mr Reynolds. Documented Risk Assessment It is our policy and standard to have a risk assessment completed at the time of admission. In Mr Reynolds's case, a risk assessment had taken place with risk indicators linked from the progress notes to the risk assessment, however, this was not in a clear form. The admission paperwork for the 136 suite has been revised to incorporate the risk headings recommended by the Royal College of Psychiatrists. The adoption of this new paperwork ensures risks are clearly identified for detainees and its success will be evaluated in 3 months. Record on Rio The nurse-in-charge should have made an entry on the RIO record. Staff are encouraged to make their written record in as close a proximity to any assessment or event taking place as possible: Since the inquest; we have examined the audit trail:of entries on RIO and determined that the entry was made on RIO:at 00.11 hours, which was not long after staff had | finished dealing with the incident and participating in the debrief. The day-time nurse in charge | did not go off duty until 23.00 hours (one and a half hours beyond the end of her shift) in order | to handover all necessary information and support staff. The nurse in charge at the time Mr Reynolds was accepted onto the unit did not make any entries on RIO, but gave handover to the nurse in charge at night who updated the RIO record accordingly. Priority had to be given the traumatic incident when it occurred and in those most difficult of circumstances, the timeliness of documenting on RIO was unfortunately compromised. Chair Trust Headquarters . Chief Executive Anthony Gallagher Jenner House, Langley Park, Chippenham, § SN15 1GG lainTulley ‘We are a teaching, learning and research trust; we aim to inform you about relevant opportunities, unless you tell us otherwise.’ Observation Levels Standards and guidance are‘in place to govern the settings of observation levels. The Trust provides a range of training programmes for staff to support them in risk assessment and observation. | am pleased to ‘confirm that staff on Mason Unit were up to date with their training. Additionally registered staff are supported in their roles through the provision of a Clinical Toolkit. The Toolkit includes specific modules on undertaking mental state examinations and risk assessment. Additionally, | am taking the following actions to improve patient safety: e Reviewing our Observation Policy to take account of revised guidance from the National Institute for Health and Care Excellence - “NICE NG10 Violence and aggression: short- term management in mental health, health and community settings”. This Guidance includes definitions on the levels of observations which need to be reflected in our policy and practice. e Reviewing staffing levels on the Place of Safety suite as part of the wider national Safer Staffing initiative, to ensure optimal staffing levels at all times, which will in turn support timely observations and recording of information. e Continue the implementation of the ‘Safewards’ interventions already underway. Research has demonstrated that incidents of harm to self and others can be reduced through the implementation of the ‘Safewards’ Interventions as observation alone is insufficient and can increase risks. If you require any further information regarding any of these initiatives, then please do not hesitate to let me know. Yours sincerely ; | lain Tulle ‘ Chief Executive ~ Waacical bs (¢ chy
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