Lorraine Bird

JAMES REUBEN MAXWELL ADAMS

REGULATION 28: REPORT TO PREVENT FUTURE DEATHS

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
Secretary of State for Health — Mr Jeremy Hunt

The Chief Executive of NHS Curnow Commissioning Group
The Chief Executive of NHS England

CORONER

| am Dr Elizabeth Emma Carlyon, the Senior Coroner for the coroner area of Cornwall

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.

INQUEST into the death of James Reuben Maxwell Adams between 27" — 29"
July 2015

CIRCUMSTANCES OF THE DEATH

tween 17.30 — 17.40 at his home address, |

on 10" August 2012 . He was found fully
clothed on the sofa with a clear plastic bag over his head with two plastic tubes
leading from the bag to two helium cylinders which were adapted to provide a
continuous stream of helium. His mobile phone was on his lap and he had head
phones attached to the phone in his ears. An almost empty bottle of vodka was
on the floor next to his feet. Suicide notes were found nearby his body. The
downstairs doors to the property were secure and the police entered through an
upstairs window. A handwritten note was seen in the window of his front door
between 10.00 - 10.30am that morning saying “Call Police”. The police were
informed at 10.55am and did not action the request until a further phone call at
around 5.00pm that day. He was last heard alive the evening before but his
door was seen open at around 1.30am that morning. He suffered from
persistent depressive disorder, alcohol dependency; and a mixed type
personality disorder and was chronically depressed. He was known to have
purchased a helium suicide kit to take his own life and was being treated by the
mental health services. The post mortem toxicological result found ethanol level
of 243 mg/100mlI which may have had a detrimental effect on motor and
cognitive function. It was not clear the intention of the note at the door window
nor was it possible to establish the time of death.

Mr Adams was chronically suicidal and the mental health services were aware of
his suicide kit and it was deemed most appropriate to treat Mr Adams in the
community at that time due to the fact that he had built up relationships with his
psychiatrist and treating mental health professionals. There were issues over
the police reaction time when there were concerns for welfare of a patient with
mental health issues in the community and the avenues open to them and
information sharing

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. —

The inquest heard how lessons had been learnt from the inquest and that the working
relationship with the Devon and Cornwall Police and the local Mental Health Services
(provided by Cornwall Partnership NHS Foundation Trust) had been improved and
formalised through appropriate protocols and Memorandum of Understanding. One
continuing difficulty was the “lack of acute psychiatric beds” in Cornwall. In addition, the
police had found that on a regular basis, the designated mental health places of safety
were not staffed to the appropriate level and the patient could not be left there. The
result of this was that patients were being inappropriately detained in police cells by way
of a safety net or were regularly being transported out of County as far as Manchester
and Bournemouth to access the appropriate acute mental health bed.

Cornwall Partnership NH Foundation Trust representative advised the Coroner that
Cornwall has pro-rata less acute mental health beds than the national average. The
preferred option for the mental health professionals was to treat local patients locally
where they are known or are able to build up relationships with the local mental health
team which is something that cannot happen if the patient is transported out of County.
Further, the treating Psychiatrist is required to travel to the out of county unit to review
the patient which results in valuable Consultant time not being available to local patients
which may need access to them at a critical time. The result of this is that unnecessary
stress is put on patients which can result in a deterioration of the patients mental health
(and possibility death) at a time when the patient needs increased support and
treatment.

ACTION SHOULD BE TAKEN

In my opinion action should be taken to prevent future deaths and | believe you
[AND/OR your organisation] have the power to take such action.

A review of the provision of acute psychiatric beds in Cornwall to avoid the transfer of
patients out of county or the use of police custody centres as a safety net.

YOUR RESPONSE

You are under a duty to respond to this report within 56 days of the date of this report,
namely by1st 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.

COPIES and PUBLICATION
| have sent a copy of my report to the Chief Coroner and to the following Interested
Persons, | have also sent it to The Chief Constable of the Devon

and Cornwall Police and The Chief Executive of Cornwall NHS Foundation Trust 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.

7™ AUGUST 2015 Dr E E Carlyon — Senior Coroner for Cornwall

eu aloutlh Sune. Colyor:

Colchester Hospital University NHS)

NHS Foundation Trust

Trust Offices, Colchester General Hospital
Turner Road

Colchester

Essex

C04 SJL

Te):
Fa:

25 September 2015

Your ref:

Mr Thomas R Osborne LL.B

HM Senior Coroner for Bedfordshire and Luton
HM Coroner's Office

The Courthouse

Woburn Street

Ampthill

Bedfordshire

NK45 2HX

Dear Mr Osborne
Re Inquest touching on the death of Lorraine Joyce Bird

As an interested person in relation to the above inquest, | have received a copy of your letter to Simon
Stevens Chief Executive NHS England dated 10 August 2015 and associated Regulation 28 report in
connection with this case. | would like to reassure you that we have taken the appropriate actions detailed in
section 5 point (2) of the report, that Lorraine Bird was not given low molecular weight Heparin when attending
Colchester General Hospital in August 2014.

The Trust has undertaken as a matter of urgency, the implementation of the Emergency Medicine Network
(GEMNet) pathway relating to Thromboprophylaxis for Emergency Department patients with acute lower limb
trauma. Approval for commencement was reaffirmed by the Thrombosis Management board on 7 September
this year and agreement is being sought from the North East Essex Medicines Management committee at the
end of September 2015. An education programme for ED staff has commenced and it is planned to introduce
the guidance as soon as funding is agreed.

| trust this provides you reassurance that our Trust has responded appropriately to the concerns raised at the
inquest and shared with NHS England.

Yours sincerely

a a & A

Dr Lucy Moore
Chief Executive

,
ae

Weve

a“

Chair: Alan Rose
Chief Executive: Dr Lucy Moore

Ne

INVESTOR IN PEOPLE,

Review of process at CHUFT to introduce Thromboprophylaxis for ED patients with acute
lower limb trauma in response to the Coroner’s concerns, following a patient death.

The Emergency Medicine Network (GEMNet), published a summary of the best available evidence
to guide the use of thrombo-prophylaxis in adult ambulatory outpatients, who present to the ED
following acute limb trauma and requiring temporary immobilisation such as back slab or cast. The
first guidance was published in 2012 and a final revision was published in September 2013. It was
recognised by the expert witness for the Coroner that although a significant number of ED
departments had not introduced this guidance at the time of the incident, it is with great regret that
this was also the case at CHUFT.

In response to this a lead consultant was identified and along with colleagues drew up a pathway
that would enable local implementation of this guidance. All the relevant parties both within the
hospital and community services were involved with development of the pathway. Implementation
was delayed due to initial lack of clarity regarding funding of LMWH and blood tests in the
community and secondly a delay in printing of a patient passport which had been planned to be
supported by an external company that included both information and a pathway of care.

The lead Consultant had a period of prolonged sick leave which caused a further delay and
therefore it was not until January 2015 that the passports and associated guidelines were available.
The lead consultant then left the trust in February 2015 and due to severe staffing constraints the
project was paused.

The trust has undertaken to implement this pathway as a matter of urgency. Approval for
commencement has been reaffirmed by the Thrombosis Management board on 7" September this
year and agreement is being sought from the North East Essex Medicines Management committee
at the end of September 2015. An education programme for ED staff has commenced and it is
planned to introduce the guidance as soon as funding is agreed.

CER

or 5
Se Chair: Alan Rose

INVESTOR IN PEOPLE Chief Executive: Dr Lucy Moore

East and North Hertfordshire NHS |

NHS Trust

pO Lister Hospital

Coreys Mill Lane
a Stevenage
Herts SG1 4AB

Mr T Osborne

Senior Coroner for Bedfordshire and Luton
The Court House vg
Woburn Street yf
Ampthill Hl
Bedfordshire
MK45 2HZ

15th September 2015

Dear Mr Osborne
Lorraine Joyce Bird (deceased)

| am writing in response to your Regulation 28 letter dated 10 August 2015, regarding
the above named.

| was saddened to learn of the death of Mrs Bird on 13 September 2014. In addition to
reading your letter, J Claims and inquests Manager, has advised me of
the pertinent issues raised at the Inquest, in particular the concerns you have regarding
Mrs Bird’s attendance to the Plaster Room at QEI! hospital on 10 September 2014.

The practitioners at both the Lister and QEIl hospitals have undertaken the required
‘British Casting Certificate and Examination in Casting Technique’ training at the Royal
National Orthopaedic Hospital and are very experienced. As a result the practitioners
have always been aware of the need to refer patients to medical staff for review in
situations where it is assessed and perceived to be anything other than a
straightforward problem with the plaster cast. At both the QEII and Lister hospitals the
plaster rooms are integrated in the Fracture Clinic where Orthopaedic surgeons are
present assessing patients. In addition, the practitioners always have access to the on-
call Orthopaedic team and can refer patients straight to the Emergency department.

Nonetheless, Mrs Bird’s tragic death has had a profound effect on the Plaster Room
practitioners, it has highlighted the importance of directing patients to medical staff in
appropriate circumstances and identified a need for further guidance.

Prior to this incident there was no written guidance available to the Plaster room
technicians. Current venous thromboembolic (VTE) guidance (incorporating NICE and
Royal College of Emergency Medicine recommendations) is under review with full
compliance with all recommendation currently anticipated for March 2016. Pending
approval and ratification of this new overarching policy, the Clinical Director for
Orthopaedics has issued immediate interim guidance to all plaster room technicians and
fracture clinic medical staff.

Chief Executive: Mr Nick Carver Ps

This guidance is attached as Appendix 1 and stipulates the circumstances under which
medical review must be sought. It should ensure that Orthopaedic surgeons are
involved in the care of any patient care who attends with symptoms that may suggest a
DVT, that a thorough review is undertaken and that any indicated medical treatment is
given in a timely manner.

Please be assured that the relevant departments in the Trust are reviewing the situation
in order to see how we should proceed in order to prevent a similar tragedy from
occurring.

In addition to the staff guidance that has been put in place, the patient information
leaflets issued by the Plaster Room have been reviewed. The current information given
to patients includes an instruction to make contact with the plaster room / emergency
department if there is any increase in pain/swelling, any change in sensation (tingling or
numbness) or the extremities change colour. In this case the existing patient leaflet was
effective as the contained information caused the patient to return to the Plaster room.

However, the leaflets do not specifically mention the risk of a deep vein thrombosis. In
addition, the leaflets do not currently include specific information regarding the
importance of maintaining mobility whilst having a limb in a cast. | will therefore ensure
that the leaflets are updated in line with the NPSA guidance on suggested minimum
mobilisation time which in turn can help prevent the complications of immobility,
including thrombosis.

| am also aware that due to the nature of ad hoc attendances, patient’s medical records
are usually not available when the practitioners review patients with cast issues.
Previously the practitioners were only making a brief record of the attendance detailing
the name, date of birth and the action taken. Following this case, the practitioners are
now recording more clinical detail in their notes including the presenting concerns, any
assessment made, the discussion with the patient, the intervention required and the
advice given. This improved documentation will have the added advantage of
demonstrating the thorough nature of the practitioners review.

| hope you will agree that the above measures will minimise the risk of a recurrence of

the tragic outcome to Mrs Bird and reassure you of our commitment to improving
services for our patients.

Yours sincerely

Nick Carver
Chief Executive

cc NHS England

Chief Executive: Mr Nick Carver [EE

En land

Professor Sir Bruce Keogh
National Medical Director
Skipton House

80 London Road

SE1 6LH

Tom Osborne LL.B 2" October 2015
HM Senior Coroner for Bedfordshire

and Luton

The Coroner's office

The Court House

Woburn Street

Ampthill

Bedfordshire

MK45 2HZ

| fm of Nursing & Quality)

Dear Mr Osborne,
RE: Inquest touching the death of Lorraine Joyce Bird

On the 10 August you wrote to NHS England requesting a response to the
Regulation 28 report in relation to Lorraine Joyce Bird. Firstly, | would like to
express my deepest sympathy to the Bird family.

NHS England has received assurance from Colchester Hospital University NHS
Foundation Trust and East and North. Hertfordshire Trust on the actions taken
following the Coroner Rule 28 Regulation Report for the death of Lorraine Joyce
Bird.

Further full detail is provided in the letters of correspondence (attached) from Mrs
Lucy Moore (Chief Executive, Colchester Hospital University NHS Foundation
Trust dated 25 September 2015 and Mr Nick Carver (Chief Executive, East and
North Hertfordshire NHS Trust), dated 15 September 2015. Specific assurances
with regard to the concerns raised by the Coroner are addressed as follows:

e The Colchester Hospital University NHS Foundation Trust has worked
closely with the Clinical Commissioning Group (“CCG”) to develop a
pathway to enable local implementation of the guidance for the use of
thromboprohylaxis in ambulatory patients requiring temporary limb
immobilisation. All relevant parties both within the hospital and community

High quality care for all, now and for future generations

services have been actively involved in this process which has been
signed off by Trust Thrombosis Management Board on the 7 September
2015 and the North Essex Medicines CCG Medicines Management
Committee on 29 September 2015.

An Education programme for the Emergency Department has been
introduced to support the implementation of the guidance. The new
pathway across primary and secondary care will commence on the 2
November 2015 as funding is not an issue for implementation.

The commissioning CCG will monitor through the Quality Review Meetings
with the Trust implementation and compliance against the guidance.

The East and North Hertfordshire NHS Trust have implemented
appropriate clinical guidance and protocol for patients attending for
treatment at the Plaster Room. This interim guidance will be reviewed by
the Clinical Commissioning Group (CCG) Medical Adviser, pending the
outcome of the review of NICE guidelines by the Royal College of
Medicine and the issuing of the full policy. The CCG will ensure the Trust
provides update guidance/training to all clinical staff within the Plaster
Room.

The commissioning CCG will agree and monitor through the Quality
Review Meeting a clear date for completion of the revised policy and
implementation of it (interim guidance already in place).

The commissioning CCG will audit the Trust on compliance against the
interim guidance and the Policy once completed alongside the associated
documentation.

The commissioning CCG will agree a timeframe for the patient information
leaflets to be updated and ensure that these are available to patients, in
light of this new guidance.

The Trust has reviewed all patient information available in the Plaster
Room and has ensured it contains effective information to alert patients to
potential complications and to recommend urgent contact with the Plaster
Room or Emergency Department in case of pain or complications

The Trust will update existing patient information regarding the importance
of maintaining mobility whilst having a limb in a cast. Patient information
will be updated in line with the NPSA guidance on suggested minimum
mobilisation time which in turn can help prevent the complications of
immobility, including thrombosis.

The Trusts and commissioning CCGs have put in place systems to ensure that
the risk of such a tragic incident reoccurring are mitigated and that all patient
information and clinical guidance is updated and implemented in line with
national protocol and guidance.

As part of NHS England's role in CCG assurance and oversight, Midlands and
East (Central Midland and East) will ensure compliance with the above corrective

High quality care for all, now and for future generations

actions through formal quarterly reviews with the CCGs and monthly NHS
England assurance forums with the Nursing and Medical teams.

Yours sincerely,

!
/

Pt \(e :

—
Professor Sir Bruce Keogh KBE, MD, DSc, FRCS, FRCP
National Medical Director

NHS England

High quality care for all, now and for future generations

From Ben Gummer MP"
Parliamentary Under Secretary of State for Care Quality

Department Richmond House
79 Whitehall

of Health itera
POCS 953428 SWI1A 2NS

Tel: 020 7210 4850
Dr E. Carlyon
Senior Coroner
The New Lodge 20 OCT 2015
Newquay Road
Penmount
Truro
TR4 9AA

Lc, hy Ceo.

Thank you for your letter of 7" August 2015 following the inquest into the death of
James Adams. I was sorry to hear of Mr Adams’ death and wish to extend my
condolences to his family.

I understand that since Mr Adams’ death the working relationship between Devon and
Cornwall Police and the local Mental Health Services has been improved and that a
Memorandum of Understanding has been drawn up.

Your main concern in this case was the lack of acute psychiatric beds in Cornwall and
how this could continue to have a adverse impact on the care of mental health patients
in this area. Commissioning mental health inpatient services is the responsibility of
the local Clinical Commissioning Group (CCG) - in this case the NHS Kernow CCG.
It commissions services for Cornwail from the Comwall Partnership NHS Foundation
Trust.

I note that you have sent your letter to both NHS England and Kernow CCG. I can
advise that Sir Bruce Keogh, National Medical Director of NHS England, is
responding to you on behalf of NHS England. I commend Sir Bruce’s reply.

NHS England’s role is to oversee the commissioning functions of CCGs.

Kernow CCG has agreed to carry out a full review both of acute psychiatric beds in
Cornwall and the staffing of the place of safety service and will produce an action plan
and commissioning strategy. The implementation of this plan will be monitored by
NHS England.

I am grateful to you for bringing the circumstances of Mr Adams’ death to my
attention and hojpe that you find this reply helpful.

(h~.

_ oo

BEN GUMMER