Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0309, written 6 Aug 2015. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 6 Aug 2015 |
|---|---|
| Reference | 2015-0309 |
| Deceased | Thomas Thurling |
| Coroner | Jacqueline Lake |
| Coroner area | Norfolk |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Norfolk and Suffolk NHS Foundation 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 ‘REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: The Chief Executive , . Norfolk & Suffolk NHS Foundation Trust Trust Headquarters Hellesdon Hospital Drayton High Road Norwich NR6 5BE CORONER lam JACQUELINE LAKE, Senior Coroner, for the Coroner area of NORFOLK 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 31 October 2014 | commenced an investigation into the death of THOMAS THEO CHARLES THURLING, age 36. The investigation concluded at the end of the inquest on 28 July 2015. The conclusion of the inquest was medical cause of death: 1a) Asphyxiation and CONCLUSION: Mr Thurling took his own life. His intention at the time is not known. . . : CIRCUMSTANCES OF THE DEATH Mr Thurling was showing increasing signs of depression and anxiety. A member of Mind went to see him on 27 October 2014 at his home but there was no response. On 28 October 2014 another member of Mind went to his home. On receiving no response Police were called and entry gained to his home. Mr Thurling was found clearly dead. 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 itis my statutory duty to report to you. The MATTERS OF CONCERN are as follows. — ° (1) On 13 August 2014 Mr Thurling’s medication was changed to help his low mood and anxiety. The Psychiatrist specifically stated that the change in medication was to be monitored to include the involvement of the CRHT Team. One Psychiatrist gave evidence (which was read) that the change in medication was closely monitored by - Mind. Mr Thurling later declined any input from the CRHT Team. His Care Co-Ordinator was unaware of the symptoms to look for. Despite close involvement, Mr Thurling’s family were unaware of the change in medication and the request for monitoring. Although Mr Thurling was seen daily by Mind they were unaware of any change in medication and the request for monitoring. An Out Patient Review was not arranged until 6 weeks later. Following that Out Patient-Review the Care Co-Ordinator was absent from work on planned and unplanned leave. Nothing was putin place to monitor the medication. (2) Care Co-ordinator was on planned and unplanned leave from end September 2014 until time of Mr Thurling’s death. Her Line Managers were aware of this continuous absence. Prior to this there had been a general deterioration in Mr Thurling's mental health noted, he was clearly expressing suicidal ideation, He had attended A & E with thoughts of suicide and he had bought a penknife and cut his neck. His mother had contacted MH Team expressing her concerns on at least 2 occasions. ; The Care Co-Ordinator had recommended a Nurse be appointed. Mr Thurling had a known fear of being abandoned by his family and MH Services. Mr Thurling was not reviewed during this period. No alternative Care Co-Ordinator was appointed. (3) It is clear from evidence given at the inquest that there is a shortage of staff at the Trust. Steps are being taken to try and address this but it is unclear as to what is being done in the meantime to cope with the difficulties that arise as a result. 6 | 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. 7 | YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 5 October 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 | have sent a copy of my report to the Chief Coroner and to the following Interested Persons: . . . | 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 fesponse, about the release or the publication of your response by the Chief Coroner. 9 | 6 August 2015 CT
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.
Norfolk and Suffolk AVF NHS Foundation Trust Trust Management 1° Floor Admin Hellesdon Hospital 10 OCT 201 Drayton High Road Hellesdon Norwich NR6 5BE Tel: 01603 421102 Fax: 01603 421118 Our ref.ml/mp 2 October 2015 Ms J Lake HM Coroner Norfolk Coroner’s Service 69-75 Thorpe Road Norwich Norfolk NR1 1UA Dear Ms Lake Regulation 28 report following the inquest of Mr Thomas Thurling | write in response to your report dated 6 August 2015. Under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 you requested the Trust consider issues of service delivery following the conclusion of the inquest into the death of Mr Thomas Thurling on 28 July 2015. You identified three matters of concern. | will address these in order: Monitoring of medication changes You identified concern regarding the systems and process employed to monitor the efficacy and safety of medication following a change in prescription. You highlighted that other key people in Mr Thurling's »_ care were unaware of the change.and how they could contribute.to. monitoring. Additionally, the . ~? Trust's staff member.had planned and unplanned leave, further conitributing to the situation. The Trust recognises that changes in medication are a significant stage in an individual's treatm and require monitoring in order to ensure it is having anticipated effects and be ready to respond, to possible side effects. ES In considering the means by which to ensure this practice is consistent, no single action will provide assurance. Recognising the task involves technical knowledge of medication and an understanding of the need to communication to the wider group of people involved in supporting the service user, we are sharing the issue with a range of leads in specific areas, such as the Pharmacy and those leading the implementation of Triangle of Care, as well as clinical teams. They will use this direction to cascade learning. ae - Further, the matter will be raised directly with clinical staff via internal communications and Glinical forums. : Chair: Gary E Page Chlef Executive: Michael Scott MINDFUL Trust Headquarters: Hellesdon Hospital, stonewall EMPLOYER -.°. -. .Drayton High Road, Norwich, NR6 SBE |. - DIVERSTYCHAMPION 1, *Tek.01603 421421, Fax: 01603 421440. www.nsfinhs.uk- moe Boggy Tee Ms Lake -2- Positively, many of our inpatient services have processes in place where the Pharmacy directly assist with providing information on medication to service users and their families. They also host a medicines information helpline which is available for service users and carers to use. The most direct means by which the Trust will know it is consistently involving all parties in communication of changes to the service user's treatment is through measures such the patient survey, incident reporting and complaints. The Trust will monitor specifically for this type of report taking remedial action where required. Care Coordinator and staffing | have linked your second and third matters of concern because they overlap. You registered concern at the arrangements to cover planned and unplanned absence of staff and how this contributes to the experience and safety for service users. In respect of cover for planned and unplanned absence of staff, the Trust has guidance for clinical teams to follow. This involves contacting the service user in order to assess the need for alternative arrangements i.e. a colleague completing visits and contacts. Clinical services have been directed to consider how they are consistently meeting this guidance with feedback and further direction via the Trust's Quality Governance Committee. In addition to these arrangements, the Trust's community services employ a duty worker system, which means that a member of staff from the team will always be available for service users or family to contact. They can respond to issues requiring urgent action or pass information to the care coordinator. Contributing to the ability to apply this guidance is the staffing levels within a team, with some areas experiencing significant pressures. The Trust is taking active steps to recruit to these areas but we have found our experiences and challenges are shared across the health sector. The Trust is taking steps to mitigate the risks by employing temporary staffing for defined periods of time. This supports an element of consistency, however, our priority is to fill our vacancies with permanent staff. This is an area of focus for the Trust's Executive and your concern mirrors ours. Thank you for bringing the matters to the Trust's attention. If | can be of any further assistance please do not hesitate to contact me. : Yours sincerely © - Michael Scott Chief Executive 205/7, at Aboy, Chair: Gary E Page ese As MINDFUL Chief Executive: Michael Scott Vis fi PLOYER Trust Headquarters: Hellesdon Hospital, Stonewall PAS Drayton High Road, Norwich, NR6 5BE DIVERSITY CHAMPION Tel: 01603 421421 Fax: 01603 421440 www.nsft.nhs.uk
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