Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0445, 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 | 2015-0445 |
| Deceased | Connor Sparrowhawk |
| Coroner | Darren Salter |
| Coroner area | Oxfordshire |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| 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:- 1. Ms Katrina Percy, Chief Executive, Southern Health NHS Foundation Trust. CORONER lam Mr D M Salter, HM Senior Coroner for Oxfordshire. 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 the 8 July 2013, | opened an Inquest into the death of Connor Sparrowhawk, aged 18, at the Short Term Assessment and Treatment Unit (STATT), Slade House, Oxford. As you will know, a Jury Inquest commenced on 5 October and concluded on Friday 16 October. 4. CIRCUMSTANCES OF THE DEATH The Jury concluded as follows:- Connor Sparrowhawk died on 4 July 2013 at STATT. No cardiac activity detected and CPR being carried out, with death pronounced at the John Radcliffe Hospital. Connor Sparrowhawk died by drowning following an epileptic seizure while in the bath, contributed to by neglect. You will be aware that the Jury also outlined further findings and failings. 5. CORONER'S CONCERNS During the course of the Inquest the evidence revealed matters giving rise to a 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 make this report to you. | place on record however the fact that significant steps and improvements have already been introduced following Connor's death. There was evidence of this from a and in the documentation that was provided. The remaining MATTERS OF CONCERN are as follows:- 1) It appears that the current recommendation at the Trust is for patients with epilepsy to be able to choose to bath but to be the subject of sight/sound observations. There are obviously difficulties in respect of patient dignity with observations by sight. As far as observations by sound are concerned, it is envisaged that a member of staff will be sat outside the bathroom door while the patient takes a bath. | am concerned however that observations by sound alone may not prevent someone from drowning. A person can drown in seconds if they are rendered unconscious by an epileptic fit. It also seems to me that a member of staff in, for example, the corridor is likely to be distracted by other members of staff and patients and may also have an occasional requirement to obtain a drink or use the toilet etc. In reality, on a busy ward, | particularly with a patient who has reasonably well controlled epilepsy, the concern is that close observation by sight/sound is urlikely to be maintained. | am concerned that this policy is simply setting the Trust up to fail. | understand that a decision was taken sometime after Connor's death to stop bathing. | also understand however that the CQC when they carried out one of their inspections was critical of this decision due to the fact that the CQC are not in favour of blanket bans of this nature. | am sending a copy of this letter to the CQC for them to comment on. My concern is therefore in relation to the effectiveness of bath time observations for patients with epilepsy. 2) The second matter of concern is in relation to RIO and the fact that there does not appear to be an appropriate prompt or place to record details about a patient's epilepsy/history. In Connor's case, this led to details of his epilepsy being placed on the care plan. Even though there have been improvements, including the introduction of the epilepsy tool kit, it is not clear whether, even now, all the required information about epilepsy can be captured on RIO and therefore, is easily accessible to staff. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe that your organisation has the power to take such action. YOUR RESPONSE You are under a duty to respond to this request within 56 days of the date of this report. | may extend the period on request. 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 | sent a copy of my report to the Chief Coroner and to the Interested Persons. 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, at the time of your response, about the release or the publication of your response by the Chief Coroner. are Monday 2 November 2015 Mr D M Salter - HM Senior Coroner
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.
Southern Health INHS| Your Ref 7’ NHS Foundation Trust Mr D.M Salter 7 HM Senior Coroner 7 Sterne Road Oxfordshire Coroner's Office Tatchbury Mount The Oxford Registry Office Calmore 2nd Floor, 1 Tidmarsh Lane Southampton Oxford $040 2RZ Ox1 INS DUREME LIAN: es Dear Mr Salter Regulation 28 Report following the inquest touching the death of Connor Sparrowhawk | am writing to you to respond to the concerns raised by your investigation into the circumstances surrounding the preventable death of Connor Sparrowhawk. In your letter of 3 November, you raised two specific concerns and | will respond to these in turn. 1. Bathing observations for people with epilepsy You recognised that a blanket ban on bathing was not considered good practice by the CQC and that line of sight observations posed difficulties in terms of patient privacy and dignity. Nonetheless you had residual concerns about the effectiveness of line of sound observations and asked the Trust to consider our practice in this regard. The Clinical Director for Learning Disability Services, has led this piece of work alongside members of the Epilepsy Clinical Area of Practice group within the division. Although a comprehensive Epilepsy Map and Toolkit have been developed which cover all areas of risk, a decision has been made to write a new protocol specifically for bathing. This has been drafted by J , Consultant Nurse, again in conjunction with a range of practitioners. The document is called Protocol for the Safe Bathing and Showering of People with Epilepsy and has just been through a consultation process among senior clinical staff members. As a result of this, suggestions have been made as to some additions that are required to make it applicable to every speciality across the Trust rather than just the Learning Disability Division. These are being incorporated in the final draft which will then be ratified through the usual Trust processes. We expect this to have happened within the next month. In the meantime, the draft document has been circulated to staff in the Trust’s learning disability inpatient units as it is already fit for purpose for use in these areas. We will send you a copy of the Protocol document as soon as it is ratified, but | would like to assure you that it is a comprehensive, evidence-based document. It includes the requirement for a comprehensive assessment, risk assessment and risk management plan to be in place. The central tenet of the Protocol is that staff must be present at all times when a person is bathing and to have the person in their line of sight, unless there is a documented reason for doing otherwise. The patient must have also had a formal, documented, capacity assessment to ensure they are able to make the decisions to participate or not participate with the risk management plan. 2. Capturing risks associated with epilepsy on RiO You were concerned that RiO, the electronic patient record, did not have an appropriate place to record details about a person’s epilepsy. This has been considered > cra who is an Informatics Clinician, the OpenRiO Learning Disability Clinical Lead and a Community Learning Disability Nurse by background. has advised me that the appropriate assessment forms from the paper based Epilepsy Toolkit are being built on OpenRiO and will be added to the next release which is issued on 28 January 2016. When change requests are made to the OpenRiO team these are ‘packaged’ together, built into the system and then released in effect as a new version of the RiO software. These Epilepsy assessments will be for the principal use of Learning Disability services, however they will also be available for use by other Trust services that would benefit from the use of specialist Epilepsy assessments. The release of the new version of RiO with the epilepsy forms will be accompanied by a comprehensive communication plan to ensure staff are aware of their availability. This will include the following: e Email to all staff across the Trust announcing the new RiO release and describing the new items included in the release e Information about new and updated forms is presented on the RiO welcome screen, where all RiO users have to manually select an information sharing agreement button prior to accessing the system e Information about the release and new items included in the regular RiO newsletter e A personalised email from[EEE to all staff working in the learning disability divisions with information about how the electronic epilepsy forms should be used e Cascade through Clinical Records Group and divisional governance groups It is important that staff record risks around all physical health problems and not just epilepsy. A change request has also been made with regards to the overarching RiO risk assessment form for mental health and learning disability services. This will provide a specific prompt for physical health risks to be noted. We expect this to be available in a future OpenRiO release planned to occur in March 2016. In the meantime, there is guidance available for staff within the comprehensive Learning Disability Service Specific Guidance for RiO which advises them that physical health risks (with specific mention of epilepsy) should be noted in the ‘Other Risk Behaviours’ section of the existing form. [EE has undertaken considerable work to promote this guidance within the division. Compliance with policies and guidelines and with record keeping standards is assessed on an ongoing basis through management supervision and the peer review process. Audits are also regularly performed with an Epilepsy audit, bathing risk audit and physical health audit having been undertaken in the learning disability division in the last quarter. The results of these are being collated and will inform further improvements that are required. | trust the information provided above gives the necessary assurance that your reflections and concerns have been taken extremely seriously and resulted in tangible changes to the way in which we manage the risks associated with epilepsy. We will send you the new Protocol for the Safe Bathing and Showering of People with Epilepsy as soon as they have been ratified, and | hope you will not hesitate to contact me should you need any further information in the intervening period. Yours sincerely Katrina Percy Chief Executive
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