Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0465, written 24 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 | 24 Nov 2015 |
|---|---|
| Reference | 2015-0465 |
| Deceased | Piotr Kucharz |
| Coroner | Alan Wilson |
| Coroner area | Blackpool and Fylde |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths · Suicide (from 2015) |
| Organisation named | Lancashire Care NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
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:
Chief Executive, Lancashire Care NHS Foundation Trust
Sceptre Point
Sceptre Way
Walton Summit
Preston
PR5 6AW
1
CORONER
I am Alan Wilson, Senior Coroner, for the area of Blackpool & Fylde
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 11 February 2015 I opened an inquest into the death of Piotr Grzegorz Kucharz
aged 37 years.
The inquest concluded on 19th November 2015.
The conclusion of the Coroner as to the death was a narrative conclusion as follows:
Piotr Kucharz took his own life after the risk of him doing so was not fully
recognised.
The medical cause of death was:
1 (a) Cerebral Hypoxia
1 (b) Ligature Strangulation .
4
CIRCUMSTANCES OF THE DEATH
Box 3 of the Record of Inquest recorded as follows:
Piotr Kucharz, previously diagnosed as suffering from, schizophrenia, was
admitted to a mental health hospital during the evening of Friday 3 October
2014.
1
Having last been seen alive at 1605 hours on Wednesday 8 October 2014, and
after subsequent and planned checks on his welfare did not take place, he was
found unresponsive and lying on the floor of his room at approximately 17.15
hours having used a cord as a ligature to strangle himself. He was taken to
hospital, where despite treatment he passed away at approximately 2200 hours on
12 October 2014. The absence of an effective translation service to assist with his
limited understanding of English, and a decision made on 7 October 2014 to
reduce the frequency of checks made on his welfare contributed to his decision to
end his life.
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. Piotr Kucharz was a Polish gentleman who commenced living in the United
Kingdom in April 2014. At the time he sought to strangle himself with a cord he
was an informal patient at the Conway Ward at Parkwood, a mental health
facility in Blackpool. At his inquest, evidence was heard from a number of
members of staff as regards what constitutes an effective observation. He was the
subject of what were described as Safety and Security [SAS] and general
observations the completion of which was the responsibility of a number of
members of care staff. The evidence heard from staff raised an area of concern
because that evidence indicated quite clearly that there was a lack of consistency
and clarity as regards what constitutes an effective observation.
An independent expert witness indicated in a report that he completed prior to
the inquest that he felt custom and practice was such that some staff were merely
checking on the “whereabouts” of the patient.
Some staff felt that they were expected to enter the room of the patient and to try
to engage with him and to check the room environment for anything that may
pose a risk to him. Others felt that whether they were expected to actually enter a
patient’s room to conduct the observation could vary depending on the level of
risk a particular patient presented, in other words that they felt they had an
element of discretion as regards whether they entered the room. This evidence
appeared to be in contrast to a Trust policy.
In the case of Piotr Kucharz, as can be seen above he had limited understanding
of English, and a number of staff gave evidence that he remained in his room
throughout his time on the Conway Ward and did not wish to engage with them.
Nevertheless, the author of the Trust’s Sudden Untoward Incident Review
document agreed that there was no such discretion and that staff ought to enter
the room to complete and effective observation.
At the conclusion to the inquest I expressed the view that I was concerned that
there is a risk of future deaths because staff remain unclear about what amounts
to an effective observation, and more specifically whether there are
circumstances which may allow them to refrain from verbally engaging with a
patient, or from physically entering a patient’s room to check the environment,
and that should that lack of consistency and clarity prevail, other patients may be
placed at risk as a result of inadequate observations.
2
For the avoidance of doubt, I confirm that I am of the opinion that the above
concern remains valid despite the fact that further to Piotr Kucharz’s death the
provision of mental health care for patient’s such as Piotr has moved from the
Conway Ward at Parkwood to another facility within my jurisdiction at which
members of staff who were working at the time of Piotr’s death continue to be
employed in a similar capacity.
6
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe you
[AND/OR 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 19th 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.
COPIES and PUBLICATION
I have sent a copy of my report to the Chief Coroner and to the following Interested
Persons:
The family of Piotr Grzegorz Kucharz
The Priory Hospital, Altrincham, Cheshire
The University Hospital of South Manchester
The Manchester Mental Health & Social Care Trust
[Consultant Psychiatrist at The Priory Hospital]
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.
8
9
A.A. Wilson
Alan Wilson
Senior Coroner for Blackpool & The Fylde
Dated: 24th November 2015
3
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 NHS Foundation Trust Sceptre Point Sceptre Way Walton Summit Preston PR5 6AW Tel: 01772 695360 Mr Alan Wilson Senior Coroner Coroner’s Office Municipal Buildings PO Box 1066 Corporation Street Blackpool FY1 1GB 08 January 2016 Dear Mr Wilson, Piotr Kucharz (deceased) – Regulation 28 Report to Prevent Future Deaths The Trust acknowledges receipt of your letter dated 24 November 2015. In the Regulation 28 report you raise the following concerns: 1. Staff are unclear what constitutes effective observation 2. Staff inconsistently applied the Observation Policy 3. The circumstances which may allow staff to refrain from engaging with a patient or from entering a patient’s room to check the environment are unclear. Shortly before Mr Kucharz died the Trust was in the process of revising its clinical risk assessment tool and policy. New standard and enhanced risk assessment tools, which sit in the Electronic Care Record (ECR), were developed by a multi-disciplinary group of clinicians. From March 2015 these tools replaced the previous Standard Safety Profile which was in use at the time of Mr Kucharz’s death. The aim of the new risk assessment tools are to improve the quality of the clinical risk assessment conducted by staff, to promote better collaboration with patients, more structured clinical risk assessment and more robust clinical risk formulations and risk management plans. This helps staff understand better the risks that patients pose to themselves and others, vulnerability and any safeguarding risks and therefore the level and type of support they need to stay safe including observations. Chair: Mr Derek Brown Chief Executive: Professor Heather Tierney-Moore OBE Since March 2015 the Trust has been training in-patient staff to use the new risk assessment tools and formulation model. This training supports staff in using the 5P's model (presenting needs, predisposing factors, precipitating factors, perpetuating factors and protective factors). We are planning an external review into the effectiveness of this new clinical risk assessment tool and policy, to be completed in April 2016 once we are twelve months into the usage of the new tool. This will provide us with robust assurance into the implementation and effectiveness of this new approach. The Trust is also in the process of reviewing the observation policy and procedure. We are taking into account the learning from previous serious incidents and national best practice. This review is currently underway and we will be developing and implementing a revised observation policy and procedure. The new observation policy and procedure will be implemented by 31 March 2016. In the interim, until this new policy and procedure is developed and implemented, an internal patient safety alert has been issued to remind staff of the current policy and procedure. This alert was sent to all inpatient services across the Trust. I hope this addresses your concerns and wish to assure you that we are keen to learn and improve the care we provide, to prevent similar incidents in the future. Should you require any further information the Trust will be more than willing to assist. Yours sincerely Dee Roach Executive Director of Nursing and Quality Chair: Mr Derek Brown Chief Executive: Professor Heather Tierney-Moore OBE
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