Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0408, written 22 Oct 2015. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 22 Oct 2015 |
|---|---|
| Reference | 2015-0408 |
| Deceased | Diane Knight |
| Coroner | John Tomalin |
| Coroner area | Exeter and Greater Devon |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Devon Partnership NHS 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.
ANNEX A 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. Ms Melanie Walker, Chief Executive of Devon Partnership Trust. 1 | CORONER | am John Geoffrey Tomalin Deputy Coroner, for the coroner area of Exeter and Greater Devon. 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 3" February 2015 | commenced an investigation into the death of Diane KNIGHT, 61 years old. The investigation concluded at the end of the inquest on 7" October 2015, The conclusion of the inquest was ‘Took her own life’. 1 (a) Hanging 4 | CIRCUMSTANCES OF THE DEATH Diane Knight had a significant history of mental illness including Depression Anxiety going back to 2012 following a diagnosis of Osteoporosis. She received various treatments both drug related and ECT. There have been several attempts by Mrs Knight to end her life by drug overdose. On the 3rd February 2015, whilst as a voluntary patient of the Ocean View Ward of North Devon District Hospital in Barnstaple, she hung herself with her beit from the door to her room. Her room has a door in which there is a window with a shutter that can be opened both from the inside and the outside. However it appears to have been an acceptable practise where patients could cover the outside of this window with a towel to stop light intrusion at night, when staff checked on the patients, to prevent light from entering their rooms and disturbing their sleep at night. Diane Knight had put a towel over her door and the window but that towel had hidden a belt end that was trapped by the door against the door-jamb from which she managed to hang herself. 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) The continued practice of putting a towel over the door could hide an attempt by a patient to harm themselves or end their life such as here with a belt end being trapped by the door against the door jamb. (2) The continuation of this practice may prevent staff being properly able to monitor the patients on the Unit, therefore this practice should be reviewed. (3) An alternative method for preserving patient privacy should be considered that would not allow a patient to conceal an attempt to cause themselves harm. 6 | ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe your organisation have 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 17" December 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. 8 | COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the following Interested Persons (1) EEE Husband | 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. 9 | 22°" October 2015 John Geoffrey Tomalin
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.
Devon Partnership INHS| NHS Trust ER EREeeE” eh PY Trust Headquarters. Wonford House Hospital Dryden Road Exeter EX2 5AF Mr J G Tomalin Telephone: 01392 208866 Deputy Coroner Web: www.devonpartnership.nhs.uk Exeter and Greater Devon Coroner's Office Room 226 Your Ref: JGT/RCB File No: 365/2015 Devon County Hall Exeter 14 December 2015 EX2 4QD Dear Mr Tomalin Re: Diane Knight (deceased) — DOD 03/02/15 - Inquest 3 to 7 October 2015 Regulation 28 Report to Prevent Future Deaths Thank you for your letter of 22 October 2015 which we received on the 23 October 2015 following the inquest into the death of Diane Knight. As an organisation we are committed to learning from these tragic events and have since receiving your report and recommendations taken the opportunity to share your findings with the service involved as well as across the wider trust. The Trust has undertaken a Root Cause Analysis Investigation following the death of Diane Knight; the report is currently in draft form and has been submitted to our commissioner for review and approval. A copy of the draft report has been included for information, however this may be subject to further changes once the commissioner has reviewed the report. The draft report has not yet been shared with the family. We will be sharing the report with the family once the commissioner has approved it and we would be happy to forward a copy to you at the same time. The Root Cause Analysis report contains two recommendations; both of which were accepted and the actions are being progressed. Recommendations from the Root Cause Analysis report (1) The practice of patients obscuring/covering the glass windows in their bedroom doors will be discontinued across all inpatient areas within Devon Partnership NHS Trust. A patient safety alert will be issued highlighting the risks and the actions required to be taken to eradicate this risk. (2) Clinical Governance systems across the Adult Directorate will be used to disseminate and share this report and its findings with clinical staff across the wider Adult Directorate in order to promote reflective considerations and discussion. The investigation and report has identified a specific recommendation and actions that will address the concerns you raised, and this is detailed further below. (1) The continued practice of putting a towel over the door could hide an attempt by a patient to harm themselves or end their life as here with a belt end being trapped by the door against the door jamb. Chair: Julie Dent CBE - Chief Executive: Melanie Walker (2) The continuation of this practice may prevent staff being properly able to monitor the patients on the unit; therefore this practice should be reviewed. Following discussion and review with the clinical team directly involved in the care of Diane Knight as —part of the Root Cause Analysis process-the-historical-practice of covering the bedroom-windows-with— a towel to minimise light intrusion has been discontinued. A trust wide safety briefing has been produced and was published on our Trust intranet, this is accessible to all staff and is one of the ways in which we publish and share learning across our services. This briefing was also included in our ‘on-line news’ which is sent out by email to all staff. The briefing stated - ‘The Trust has received a Rule 28 from the Coroner in relation to the continued practice of putting a towel, or any other item likely to prevent staff properly observing or monitoring the patient through the window of bedroom doors (to stop light intrusion), as there is a risk that putting a towel or similar item over the door could hide an attempt by the patient to harm themselves or end their life such as in this particular case. The alert applies to all inpatient areas across the Trust and requires immediate action and compliance.’ A copy of the safety briefing is attached for your information. We plan to issue a further local alert to all inpatient units which will be sent using our alerts process; this requires a formal response from each ward confirming that the alert has been reviewed and appropriate action taken. This is going to be sent once the RCA report has been agreed so any further actions from the commissioner's review can be included. This is due to be completed by the end of January 2016 (following agreement of the report by the commissioner). (3) An alternative method for preserving patient privacy should be considered that would now allow a patient to conceal an attempt to cause themselves harm. The wards and individual rooms are designed to provide patient privacy whilst maintaining the ability to manage an individual's safety, however as in this tragic case, the practice of covering the observation windows; which are designed to be obscured when needed by means of a physical lever in the window has resulted in the patient being able to conceal themselves. and the implement used to assist in the suicide. We are in the process of developing our Respect and Dignity Audit; we will be including a specific requirement for teams to consider how they maintain privacy in these types of situation and what more can be done to keep patients safe whilst maintaining their privacy. This audit will then inform any wider actions needed. The audit is due to be completed by the end of January 2016. | hope that the actions described demonstrate our commitment to the learning we have undertaken. If you required any further information please do not hesitate to contact me. Yours sincerely \ Director of Nursing and Practice On behalf of Melanie Walker, Chief Executive Chair: JulieDent CBE - Chief Executive: Melanie Walker
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