Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0504, written 8 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 | 8 Oct 2015 |
|---|---|
| Reference | 2015-0504 |
| Deceased | Rebecca Jones |
| Coroner | Edward Thomas |
| Coroner area | Hertfordshire |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Hertfordshire Partnership University NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
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Vig sd 4 CORONER’S OFFICE DISTRICT OF HERTFORDSHIRE The Old Courthouse, St Albans Road East, Hatfield, Hertfordshire, AL10 OES DX: 100702 Hatfield Tel: 01707 292780 Fax: 01707 897399 MR EDWARD THOMAS Senior Coroner GRAHAM DANBURY Deputy Coroner Or FRANCES CRANFIELD, ALISON GRIEF, EDWARD SOLOMONS Assistant Coroners 8 October 2015 The Rt Hon Jeremy Hunt MP Secretary of State for Health Department of Health 79 Whitehail London SW1A 2NS Your Ref: to be advised Our Ref: 02049-2013 Dear Mr Hunt, Re: Rebecca Emily JONES, deceased | am writing to you under the provisions of Schedule 5 (paragraph 7) of the Coroners & Justice Act 2009 which came into force in July 2013. This re-enacted the provisions of the old Rule 43 of the Coroners Rules 1984. Attached to this letter is information concerning the new rules and regulations from which you will see requires a written response. Copies of this letter and the response received from you will be forwarded to the other interested persons identified at the inquest in accordance with the list attached. | am also sending a copy of this letter to the Department of Health for their general information. Please find enclosed a copy of the Record of Inquest from which you will note that the jury’s findings in respect of a number of matters. Becky (a name she was always known by) was known to mental health services since she was an adolescent and had a number of admissions to hospital under detention and also the use of Section 136. On the 22"4 August 2013 she was found near a railway line in a confused state and acting in a way that was dangerous to herself. Police detained Becky under Section 136 and brought her to the 136 Suite at the Lister Hospital, Stevenage; a facility that had been used for a number of years. | heard evidence from the Head of Public Protection at Hertfordshire Constabulary, Detective Superintendent Hanlon, that there had been no use of police cells in the purposes of Section 136 for a number of years. It is clear that police cells should only be used as a very last resort in matters like this, but it is therefore incumbent upon those providing the 136 facilities should ensure that they provide a safe containment pending the assessment that must take place within a reasonable period of time. fe... Page Two Becky JONES Becky was brought into the Section 136 Suite just after midnight on the 23 August 2015. in accordance with their protocol (which was accepted by the jury as reasonable) police officers left the unit following a joint assessment with the bleep holder as it was deemed that Becky posed a Low Risk for the purpose of containment within the Section 136 Suite. She presented no management problem, was compliant and placid and was not wanted on the police national computer. Thereafter the assessment under Section 136 was not able to be carried out within the three hours expected in accordance with the joint protocol, because an urgent assessment was required for two other vulnerable persons with learning difficulties in the community who were threatening self-harm. As Becky was “in a place of safety” it was felt that the community assessments had to take priority. However, the jury found during evidence that there was inadequate supervision of Becky, who was last seen at about 04:00 then discovered to be missing when the assessing team came to interview her at 05:30. Becky was found dead at about 09:00 later that morning in the open on ground below as service ramp near the mortuary entrance at the Lister Hospital. Cause of death was multiple traumatic injuries, to her head as she had fallen from a height. The window of the 136 Suite had been left open for ventilation and although there were restrictors the window was replaced quickly to a fixed non opening window. There was no CCTV camera surrounding the 136 room but one has now been installed so that images can be viewed by the mental health reception staff and staff covering the Aston Ward. The CCTV also covers the corridor leading to and from the 136 Suite. Emergency door releases on the 136 room and on the rear corridor of the ground floor of the mental health unit, both operated by push buttons were also replaced by key operated door release, and all windows in the mental health unit are to be fitted with restrictors. The windows in the toilets and baby changing area on the 136 corridor had window mesh fittings added to the fanlight opening. The window in the 136 Suite room was at ground floor level and during the inquest our attention was drawn to an Estates and Facilities Alert from the Department of Health under reference EFA-2013-002 issued 23 January 2013. This indicated that window restrictors may be inadequate in preventing a determined effort to force a window open beyond the 100mm restriction. We were given to understand that this primarily aimed at preventing falls through windows from a height, but it should equally apply to spaces where ventilation was needed in rooms containing vulnerable people, irrespective of floor height, to prevent them leaving via the window. | am drawing your attention to these changes that have been made as it may well be that other Section 136 Suites, particularly those that have been of longstanding use may not be designed or equipped in such a way to prevent a person in a place of safety from absconding. The jury found that the major contribution in Becky's absconding was the absence of continuous observation. We also heard evidence regarding bleep holder training. Although it was clear that some training was given, the Hertfordshire Partnership University NHS Foundation Trust has decided to operate a more focused training programme for bleep holders especially as it is also now apparent that the use of Section 136 has increased dramatically over the last year. | heard evidence that the $136 had been used over 500 times in the year up to April 2015. An examination of bleep holder training offered by other Trusts may well be appropriate. Cont'd ha. Page Three Becky JONES Becky was a student at Sheffield University and came back to Hertfordshire after a stay being an in-patient in a psychiatric unit in Sheffield. She was brought down by the discharge nurse with a discharge summary in July but unfortunately there was no care programme meeting arranged for the continuation in relation to her care. In addition, perhaps in accordance with Becky's preference, her care coordinator was her psychiatrist with whom she appears to have had a good relationship. However, it was agreed that it might have been more appropriate for her to have had a care coordinator from another professional from the team as the psychiatrist was sadly not kept informed in relation to assessments that were taking place after she presented in an Accident and Emergency Department following overdoses or thoughts of self- harm. The importance of good communication for patients who are being transferred to other areas and within a team, ensures that any worrying signs can be noticed leading to support and action as required. Although this maybe not a critical factor in relation to this tragic death, i thought | would draw this to your attention for encouragement for other mental health trusts of better communication between and amongst themselves. The Hertfordshire Partnership Trust has now arranged for spot checks to be carried out by senior staff by walking through such units and seeing what is going on. This seems to be a very good practice that | feel other Trusts may wish to consider. The schedule requires a response from you within 56 days of receipt which | calculate is the 3° December 2015. Please let me know if there are difficulties in complying with this timescale. | am retiring as Senior Coroner on the 31* October 2015 but | have discussed this report with my successor, Mr Geoffrey Sullivan. Yours sincerely Edwar Senior/Corongr
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.
Rt Hon Alistair Burt MP Minister of State for Community and Sacial Care wy “CEIVED Department 07 DEC 2015 of Health Richmond House 79 Whitehall London SWITA 2NS Tel: 020 7210 4850 Mr E. Thomas, Senior Coroner, The Old Courthouse, St Albans Road East, 03 Lie 1018 Hatfield, Hertfordshire, AL10 OES Derm Me Thomas - Thank you for your letter of 8 October 2015, following the inquest into the death of Rebecca Jones. I was sorry to hear of Ms Jones’s death and wish to extend my condolences to her family. You raise four concerns as a result of this case: the design of Section 136 Suites; the importance of continuous observation of the mental health patient; the training provided for bleep holders; and the need for good communication between mental health trusts. Although steps have already been taken by the Hertfordshire Partnership University NHS Foundation Trust to address these concerns, you suggest that such issues might need to be addressed across all Mental Health Trusts. Both NHS England and the Care Quality Commission (CQC), through the winter resilience programme and the annual survey of health based places of safety respectively, are aware that some areas still do not have adequate capacity for health- based places of safety. To remedy this, NHS England is spending £15m in 2016/17 to boost provision in those areas that need it most. This will include improving standards in existing places of safety to ensure that they are equipped to care for people safely and compassionately when detained under the Mental Health Act. NHS England, as part of its national crisis care programme, will be developing commissioning guidance for effective crisis response. This will include specific guidance on health-based places of safety and the clinical and physical standards of s.136 suites. This process will have a multi-agency group including leading experts from healthcare, policing, social care, and other representatives. Part of this work will see the development of national datasets so that standards of mental health crisis care can be measured and made transparent at a national level. The CQC has also undertaken valuable work focussing on health based places of safety. In October 2014, they published the report, A safer place to be, which details findings from a survey to examine the provision, use and accessibility of health- based places of safety for people detained under section 136 of the Mental Health Act. In June 2015, CQC published, Right here, right now, a review of the quality, care and effectiveness of care provided to those experiencing a mental health crisis. Both of these publications fulfilled some of CQC’s commitments under the national Mental Health Crisis Care Concordat, a national agreement setting out how health, policing and local government partners should improve their responses to people experiencing a mental health crisis. CQC has also selected health-based places of safety as one of the core services to be regularly inspected as part of its comprehensive inspection activity for specialist mental health services. In addition, local multi-agency Concordat action plans have been in place across the whole of England since May 2015, and local partnerships are working together to review their section 136 protocols as part of this process. Your second concern relates to patient observation. You report that the lack of continuous observation was a factor in Becky’s absconding. However, her initial low risk assessment on admission to Lister Hospital’s Section 136 Suite should have determined the level of patient observation that was considered necessary at the time. There is guidance for professional staff in this area. The Mental Health Act Code of Practice is clear that increased levels of observation (which includes intermittent observations) may be used to prevent suicide or serious self-harm. Levels of observation and risk should be regularly reviewed and a record made of agreed decisions in relation to increasing or decreasing the observation. NICE have also produced guidelines. Guideline 25, “The short term management of disturbed/violent behaviour in in-patient psychiatric settings and emergency departments” recommends nationally prescribed levels of observation based on the patient’s risk level. a Department of Health Although such observation guidelines exist, their implementation is a matter for each local NHS Trust. However, I would expect all hospitals to have clear written policies on the use of observation. This should include requirements to record when observations are carried out and the findings. The National Confidential Inquiry into Suicide and Homicide (NCISH) undertook a review of constant and intermittent observation on mental health units entitled, “Jn- patient suicide under non-routine observation” published in March 2015. Current observation approaches were found not to be safe enough and new models should be developed and evaluated. NHS England will ensure that the recommendations of the - NCISH report, including those which relate to improving the reliable delivery of effective observation, are considered and implemented. “Bleep holder” training is part of Continuing Professional Development (CPD) and such training is primarily the responsibility of employers. However, Health Education England (HEE) spends approximately £215million per year on activities which together are termed as ‘workforce development’. HEE is undertaking a root and branch review of its workforce development spend, in response to its mandated commitment to ensuring professional and personal development beyond the end of formal training. The Health and Social Care Act places a duty on the health system to promote autonomy for providers of healthcare or those that provide services that assist that purpose. Although HEE cannot impose specific CPD activities on employers or the workforce, it endorses the policy of Hertfordshire Partnership University NHS Foundation Trust in providing more training for bleep holders adopted in the wake of Ms. Jones’ death. It is vital that there is good communication between professionals across agencies to ensure continuity of care for the patient and to provide the most appropriate support for patients whenever and wherever they present to a service. NHS England recognises the importance of effective, timely and appropriate transfer of key information that follows the patient through the healthcare system. Working with partners, NHS England is currently developing a range of tools and guidance to support commissioners and providers in the transformation of urgent and emergency care services. This will include use of enhanced summary care records and will enable better access to patient care plans, end of life care records, special patient notes and mental health crisis notes. Such moves will help to improve communication between mental health trusts and ensure that those caring for patients transferred between services are kept fully informed of the patient’s care needs. I am grateful to you for bringing the circumstances of Ms Jones’s death to my attention and hope that you find this reply helpful. la Sin cael Auk #- — ALISTAIR BURT
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