Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0421, written 2 Nov 2015. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 2 Nov 2015 |
|---|---|
| Reference | 2015-0421 |
| Deceased | Jacqueline Williams |
| Coroner | Caroline Beasley-Murray |
| Coroner area | Essex |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
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REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: The Chief Executive Officer East Lancashire NHS Foundation Trust Trust Headquarters The Royal Blackburn Hospital Haslingden Road Blackburn BB2 3HH CORONER I am Michael Singleton, Senior Coroner for the Coroner area of Blackburn, Hyndburn & Ribble Valley. CORONER’S LEGAL POWERS I 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 the 28" January 2018 I commenced an investigation onto the death of Jacqueline Williams aged 42. The investigation concluded at the end of the Inquest which was concluded on the 28" October 2015. The conclusion of the Inquest was that Jacqueline Williams had committed suicide. CIRCUMSTANCES OF THE DEATH On the evening of Monday 26" January 2015 Jacqueline Williams was conveyed by ambulance to the Royal Blackburn Hospital where she was triaged and assessed to be at moderate risk of self-harm. A decision was made that she should be referred directly to the Mental Health Liaison Team. Due to a breakdown in communication between the triaging nurse and the Mental Health Liaison nurse no actual referral was accepted by the Mental Health Liaison Team. Having been placed in a cubicle within the emergency department at the Royal Blackburn Hospital Jacqueline Williams hanged herself from the central observation light using the electrical cord tied around her neck. 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 further deaths will occur unless action is taken. In the circumstances it is my duty to report to you the MATTER OF CONCERN is as follows: - That the process of referral to the Mental Health Liaison Team was subject to human error and that the systems in place failed to provide for such mistakes to be easily identified and rectified. In particular there was no opportunity for staff in the emergency department to see confirmation that a referral had been accepted, the time of that referral and the expected time when a mental health assessment would take place. Likewise the Mental Health Liaison Team did not have a process that whereby they were able to identify those patients that the staff in the department believed had been referred and were awaiting assessment. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I 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% December 2015. I, the Coroner, may extend this 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 person, namely: Lancashire Care NHS Trust Tam 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. 02 November 2015 Signed by: ...ccccscceleeKeDiCacctratgeastteePoagscerssessen H M Senior Coroner for Blackburn, Hyndburn & Ribble Valley tv REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: The Chief Executive Officer Lancashire Care NHS Trust The Innovation Centre 1 Evolution Park Haslingden Road Blackburn BB2 2FD CORONER I am Michael Singleton, Senior Coroner for the Coroner area of Blackburn, Hyndburn & Ribble Valley. CORONER'S LEGAL POWERS I 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 the 28" January 2018 I commenced an investigation onto the death of Jacqueline Williams aged 42. The investigation concluded at the end of the Inquest which was concluded on the 28" October 2015. The conclusion of the Inquest was that Jacqueline Williams had committed suicide. CIRCUMSTANCES OF THE DEATH On the evening of Monday 26'" January 2015 Jacqueline Williams was conveyed by ambulance to the Royal Blackburn Hospital where she was triaged and assessed to be at moderate risk of self-harm. A decision was made that she should be referred directly to the Mental Health Liaison Team. Due to a breakdown in communication between the triaging nurse and the Mental Health Liaison nurse no actual referral was accepted by the Mental Health Liaison Team. Having been placed in a cubicle within the emergency department at the Royal Blackburn Hospital Jacqueline Williams hanged herself from the central observation light using the electrical cord tied around her neck. 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 further deaths will occur unless action is taken. In the circumstances it is my duty to report to you the MATTER OF CONCERN is as follows: - That the process of referral to the Mental Health Liaison Team was subject to human error and that the systems in place failed to provide for such mistakes to be easily identified and rectified. In particular there was no opportunity for staff in the emergency department to see confirmation that a referral had been accepted, the time of that referral and the expected time when a mental health assessment would take place. Likewise the Mental Health Liaison Team did not have a process that whereby they were able to identify those patients that the staff in the emergency department believed had been referred and were awaiting assessment 6 ACTION SHOULD BE TAKEN j In my opinion action should be taken to prevent future deaths and I believe you 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 21% December 2015. I, the Coroner, may extend this 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 I have sent a copy of my report to the Chief Coroner and to the following interested person, namely: East Lancashire Healthcare NHS Trust Tam 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 02 November 2015 SIQMed by! ..rcoccssseseccccseccnesscnsssersersvansvencues ones H M Senior Coroner for Blackburn, Hyndburn & Ribble Valley
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: South Essex Mental Health Partnership Trust 1 CORONER I am Mrs Caroline Beasley-Murray, HM SENIOR Coroner, for the area of Essex 2 CORONER’S LEGAL POWERS I 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 21st May 2015 I commenced an investigation into the death of David John Pooley. The investigation concluded at the end of the inquest on 30th October 2015. The cause of death was 1a) Hanging. The conclusion of the inquest was a Narrative Conclusion;- David Pooley killed himself whilst suffering from depression. David John Pooley’s risk of self harm/suicide was not properly and adequately assessed and reviewed. CIRCUMSTANCES OF THE DEATH 4 Mr Pooley who was 66 years old, was admitted to Basildon Hospital on the 5th May 2015 following an attempt to hang himself in his own home. He spent time in the Mental Health Assessment Unit and he was then transferred to Gloucester Ward. He was found hanging in the toilet on the ward and his death was confirmed at 6:38am on the 20th May 2015. 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. Contrary to the trust’s policy, there was no named nurse allocated until the day before Mr Pooley’s death. The role of the named nurse had not therefore been carried out – this entails the devising of a risk assessment, care plans, one to ones, contact with the patient’s family etc. 2. The appropriate assessments and reviews were therefore not carried out. 1 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 15th January 2016. 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 I have sent a copy of my report to the Chief Coroner and to the following Interested Persons. Mr Pooley’s Family. I 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 3rd November 2015 Mrs Caroline Beasley-Murray 2
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.
Lancashire Care INHS| NHS Foundation Trust Lancashire Care NHS Foundation Trust Sceptre Point Sceptre Way Walton Summit Preston PR5 6AW ' Tel: 01772 695360 Mr. Michael Singleton Senior Coroner Coroner's Office Blackburn Central Library Town Hall Street Blackburn BB2 1AG 30 November 2015 Dear Mr. Singleton, Jacqueline Williams (deceased) — Regulation 28 report to prevent future deaths The Trust acknowledges receipt of your letter dated 2 November 2015. In the regulation 28 report you raise the following concerns: 1. The process of referral to the Mental Health Liaison Team is subject to human error 2. The referral process does provide opportunity for staff in the emergency department to see conformation that a referral has been accepted and when they can expect an assessment to take place 3. The Mental Health Liaison Team do not have a process to identify patients that the staff in the emergency department believe they have referred for assessment. Following this incident we undertook a joint investigation with East Lancashire Hospitals NHS Trust. This resulted in the development of an action plan to implement measures to improve safety and prevent such a tragic event from recurring. We continue to implement this action plan and work closely with East Lancashire Hospitals NHS Trust and the commissioning groups for East Lancashire and Blackburn with Darwen. Below are details of the actions that have been taken to date and those that are planned that address the concerns of your regulation 28 report. In the immediate term, we have briefed all staff on the referral process to ensure they fully understand that process and shared the learning from our joint investigation. We have also met with East Lancashire Teaching Hospitals NHS Trust to explore in detail how we can improve the referral process. S vovortins Health and Wellbeing Ys MINDFUL, EMPLOYER Lancashire Care |NHS| NHS Foundation Trust Within the Emergency Department they use the CRISP board to record the referrals made to specialists teams and we are looking to utilise this technology. A further option we are exploring is the development of a system whereby East Lancashire Hospital NHS Trust staff email the Mental Health Liaison Team with the patient's details and a brief reason for referral. The Mental Health Liaison Team would then acknowledge receipt of the email and also give approximate time of assessment. The referral information is already recorded within the Mentai Health Liaison referral log book, however this approach we are looking to implement will ensure that positive confirmation is provided to Emergency Department staff. | hope this addresses your concerns and wish to assure you that we are keen to implement systems to prevent similar incidents in the future. Should you require any further information the Trust will be more than willing to assist. Yours sincerely Ba, Cad Dee Roach Executive Director of Nursing and Quality Swovorting Health and Wellbeing ys \) say MINDFUL EMPLOYER
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