Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0480, written 24 Dec 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 Dec 2015 |
|---|---|
| Reference | 2015-0480 |
| Deceased | Christopher Higgins |
| Coroner | Jacqueline Lake |
| Coroner area | Norfolk |
| Category | Suicide (from 2015) |
| Source | judiciary.uk record · original PDF |
| Responses published | 3 |
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. Chief Executive Norfolk & Suffolk NHS Foundation Trust Fermoy Unit Queen Elizabeth Hospital Gayton Road, King’s Lynn Norfolk, PE30 4ET 2. Chief Executive Queen Elizabeth Hospital Gayton Road, King’s Lynn Norfolk, PE30 4ET 3. Chief Executive ‘Norfolk & Norwich University Hospital Colney Lane, Norwich NR4 7UY 4. Chief Executive James Paget University Hospital Lowestoft Road Gorleston, Great Yarmouth Norfolk, NR31 6LA 1 | CORONER lam JACQUELINE LAKE, Senior Coroner, for the coroner area of NORFOLK 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 16 July 2013, | commenced an investigation into the death of CHRISTOPHER JONATHAN HIGGINS, AGE 36 YEARS. The investigation concluded at the end of the inquest on 16 DECEMBER 2015. The conclusion of the inquest was Medical Cause of Death: 1a) Severe head injury with extradural haeniorrhage (operated on) and Conclusion: Suicide 4 | CIRCUMSTANCES OF THE DEATH On 23 December 2013 Mr Higgins became a voluntary patient at the Fermoy Unit. On 24 June 2013 Mr Higgins self-harmed resulting in a wound to his neck. He was taken to the Accident and Emergency Department, Queen Elizabeth Hospital, King’s Lynn. Whilst being treated, Mr Higgins grabbed a pair of scissors and repeatedly stabbed himself in the chest. He was restrained. Mr Higgins received medication and was returned to the $136 Suite at the Fermoy Unit. Whilst there he was taken out for a cigarette and dived over the railings landing on the ground below, sustaining a head injury. Mr Higgins was taken to the Queen Elizabeth Hospital, King’s Lynn and then transferred to Addenbrooke's Hospital where he died as a result of the head injury on 2 July 2013. 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) It became clear during evidence, that members of staff are not aware of what is required of them when they carry out Observations on a patient. This was particularly evident with regard to Observations to be carried out on a “two members of staff to one patient” basis. Areas of confusion include how staff are to engage with a patient, how close they are.required to be with regard to the patient, i.e. at arm’s length or within eyesight and how to record the information gained from the Observation. (2) The Escort Policy does not include information relating to the transfer of patients from one place to another (in this case from an Acute Hospital to the Fermoy Unit) when other services are involved, for.instance the Police. In particular, Mr Higgins who had been acting in an unpredictable and paranoid manner, was put into a cage at the rear of the Police van with three Police Officers, with no Mental Health staff to accompany him. The evidence did not reveal that this had been considered by the Mental Health staff previously attending to Mr Higgins; ; (3) The safety of the environment where the incident took place, namely a disabled ramp with a railing along the edge and a concrete’floor, had not been risk assessed prior to taking Mr Higgins outside for a cigarette. It is understood that since Mr Higgins’ death the railing has been heightened. There was no evidence of a formal Risk Assessment having been undertaken since his death. Other ways of making the area safe are still under consideration. (4) There is no agreement in place between the NSFT and the Acute Hospital as to the best way to deal with patients subject to detention under the Mental Health Act who require assessment and treatment at A & E, as a result of which Mr Higgins, was required to wait over 2 hours in a busy, public area, having already self-harmed and shown signs of paranoia. ACTION SHOULD BE TAKEN -In my opinion action should be taken to prevent future deaths and | believe your organisation has 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 18 February 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 | have sent a copy of my report to the Chief Coroner and to the following Interested Persons: (parents) Norfolk County Council Norfolk Constabulary Cambridge Constabulary Department of Health Healthwatch Norfolk - | have also sent it to CARE QUALITY COMMISION 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. 24 December 2015 J aKa. Jacqueline Lake Senior Coroner for Norfolk
3 responses 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.
“1-8 FEB 2018 James Paget University Hospitals NHS) NHS Foundation Trust Lowestoft Road Gorleston 415" February 2016 , Great Yarmouth Norfolk Private and Confidential NR31 6LA Mrs Jacqueline Lake Main Switchboard: 01493 452452 Senior Coroner for Norfolk . ; 69 — 75 Thorpe Road ; ; Direct Norwich : Direct Fax: NR1 1UA Dear Mrs Lake RE: Regulation 28 Report to Prevent Future Deaths following the inquest into the death of Mr Christopher Higgins Thank you for your letter dated 24" December 2015 following your inquest into the death of Mr Christopher Higgins. Although the Trust was not an Interested Person at the inquest, | understand that the inquest raised concerns that there was no arrangement in place between Norfolk and Suffolk Mental Health Trust and any of the acute hospitals in Norfolk to alleviate, as far as possible, distress to any patient detained under the Mental Health Act. Hence, you have made 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. We have considered the issues you raised in your report and we have worked with colleagues at Norfolk and Suffolk Mental Health Trust to develop a process for ensuring that patients under the care of mental health services who require acute care, either planned or as an emergency, have a clear pathway which includes agreed communication channels between clinicians, to expedite that care and reduce any potential for distress. Together we have developed a flow-diagram to describe this process which is being used with immediate effect. | have attached a copy of this flow-chart for your information. We will monitor adherence to this new agreed process via the regular operational liaison meetings between our two trusts. | would like to thank you for bringing your concerns to my attention. Please do not hesitate to contact me if you require anything further. Yours sincerely Christine Allen Chief Executive
. Ferrey Ua | 18 FEB 2016 Norfolk and Suffolk INHS| NHS Foundation Trust ‘ Trust Management 4° Floor Admin . Hellesdon Hospital Drayton High Road Hellesdon Norwich NR6 5BE Tel: 01603 421102 Fax: 01603 421118 Our ref.ml/mp 15 February 2016 Ms J Lake HM Coroner Norfolk Coroner's Service 69-75 Thorpe Road Norwich . Norfolk NR1 1UA Dear Ms Lake Regulation 28 report following the inquest of Mr Christopher Higgins | write in response to your report dated 24 December 2015. Under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 you requested the Trust consider issues of service delivery following the conclusion of the inquest into the death of Mr Christopher Higgins on 16 December 2015. You identified four matters of concern. | will address these in order: Observations © Your report identified that during the inquest staff reported areas of confusion regarding the action of additional observations. The staff conveyed a lack of clarity regarding aspects such as arm’s length or within eyesight. Following the inquest the Trust's Observation and Engagement of Service Users policy has been reviewed and updated to reflect the néed for clarity in applying the observations as intended. | enclose a copy of the policy. , Amending policy is one action, which must be followed by communication to ensure its adoption by all staff. The Trust uses a range of communications including updates by email, within a Patient Safety Newsletter and discussion at governance and leadership forums. Through this range of means, staff are updated of the requirement to adapt practice. Escorting/Transferring patients from one place to another when other services are involved. Your report reflected the fact that Mr Higgins was transferred in the Police van back to the Fermoy Unit without a member of mental health staff present. Accepting that in Mr Higgin’s case the travel time and distance was small (within the site), the Trust acknowledges how important this cari be for the patient. Therefore the Trust will be strengthening its policy direction (the policy is further at boy, Chair: Gary E Page $ “fe ay Chief Executive: Michael Scott 3 £ Vi MO LOVER Trust Headquarters: Hellesdon Hospital, Stonewall PAG Drayton High Road, Norwich, NR6 5BE. DIVERSISY CHAMPION Tel: 01603 421421 Fax: 01603 421440 www.nsft.nhs.uk Ms Lake ~2- referenced below) that staff should wherever possible, accompany the patient during the transfer. There may be some limited instances where this is not possible on the grounds of safety but decisions would be made in liaison with the other service involved. Safety of the environment where the incident took place Following the incident the Trust reviewed the railing that sits with the disabled access ramp, adding additional height bars to reduce the likelihood that an individual could, from a standing position, jump over the top of them. Following the inquest the Trust has revisited the assessment of this area. Whilst there are mitigations in place such as the heightened rail and access to the area by patients is made with supervision, the ' Trust has decided to fully enclose the ramp. This work has commenced and is proposed to be completed by the end of March 2016 and removes the possibility of an individual jumping from the top of the ramp area. Agreement with acute hospitals to support timely assessment of the patient’s needs In addition to writing to the Trust, you have communicated with the local acute hospitals in Norfolk with the intention of raising to both services the consideration of how patients with mental health needs are cared for in a timely and least distressing way: The Trust is taking this matter further than the Norfolk acute hospitals instructing. managers based in Suffolk to liaise with their acute hospital colleagues as well, Each area is working to create local protocols which will be incorporated into policy. These are in progress and their completion will be reported to the Trust board. : . Thank you for bringing the matters to the Trust's attention. If | can be of any further assistance please do not hesitate to contact me. Yours sincerely Michael Scott ‘Chief Executive at ABQy, Chair: Gary E Page Sees Chief Executive: Michael Scott 3 Vi Seonnertt Trust Headquarters: Hellesdon Hospital, Stonewall Drayton High Road, Norwich, NR6 5BE DIVERSITY CHAMPION . & “isa Tel: 01603 421421 Fax: 01603 421440 wwwinsft.nhs.uk
- : - . 7 Ju Fu 2MAR 2016 The Queen Elizabeth Hospital INHS| King’s Lynn . NHS Foundation Trust a The Queen Elizabeth Hospital Gayton Road Kings Lynn Norfolk PE30 4ET www.qehklnhs.uk Your ref: JL/sd . . Legal Services ' Tel: 01553 613521 26 February 2016 Fax: 01553 613700 . Minicom: 01553 613888 Mrs. J. Lake, The Coroner, Norfolk Coroner’s Service 69 — 75 Thorpe Road Norwich ; Norfolk NR1 1UA - Dear Mrs. Lake, Re: Regulation 28 report to prevent future deaths following the Inquest: Mr Christopher Higgins “lam writing to apologise that you did not receive a response to the Regulation 28 report following the death of Mr Christopher Higgins within the timeframe set out in your letter of the 24 December 2015. We have been working closely with Norfolk and Suffolk NHS Foundation Trust to develop a referral pathway which will ensure in the future that inpatients from our local mental health facility can access care and treatment in the Emergency Department in a timely manner that limits stress to the individual concerned. Norfolk and. Suffolk NHS Foundation Trust has.coordinated this work and has developed the written pathway and flow diagram for staff, outlining a new referral route in which a potential Emergency Department attendance is flagged with the department and a mutually agreed time is arranged so that the patient can be seen immediately on arrival in the department. At the time of the inquest our understanding was that the Norfolk and Suffolk NHS Foundation Trust were already in the process of liaising with local A&E Departments and thereafter drawing up a joint response incorporating these local agreements and you may already have received further details from them. We are pleased to say that this work is now complete. The Trust currently experiences a significant level of attendance in the Emergency Department from patients presenting with mental health problems or self-harm and as such is constantly seeking ways to improve the experience for these patients. It is hoped that this planned pathway for patients from an inpatient mental health bed will improve both the experience and safety of this particular cohort of patients. : alr: Edward Libbey Ne ait Mog, Chief Executive: Dorothy Hosein GB, 84 oA Fivonewat Patron: Her Malesty The Queen . 29 February 2016 : The Queen Elizabeth Hospital King’s Lynn NHS Foundation Trust | apologise once again that we did not respond within the required timeframe but would 'like to assure you that your recommendations have been acted on and new measures agreed to improve the safety of the process of transfer and the experience for the patient. Yours sincerely, Mrs. Dorothy Hosein Chief Executive Page 2 of 2
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