Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016 – 0268, written 26 Jul 2016. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 26 Jul 2016 |
|---|---|
| Reference | 2016 – 0268 |
| Deceased | Lee Grimes |
| Coroner | Rachael Griffin |
| Coroner area | Manchester (West) |
| Category | Community health care and emergency services related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
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: 1. Mr Jeremy Alston, Chief Executive of Next Stage, Comtech House, 28 Manchester Road, Westhoughton, Bolton, BL5 3QJ 2. Mr Simon Barber, Chief Executive of 5 Boroughs Partnership NHS Foundation Trust, Hollins Park House, Hollins Lane, Winwick, Warrington 1 CORONER I am Rachael Clare Griffin, Assistant Coroner, for the Coroner Area of Manchester West 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 the 23rd March 2016 I commenced an investigation into the death of Lee Francis Grimes, born on the 12th September 1975. The investigation concluded at the end of the Inquest on the 13th July 2016. The Medical Cause of Death was: 1a Acute Left Ventricular Failure 1b Cocaine Induced Cardiac Ischaemia The conclusion of the Inquest was Drug Related Death. 4 CIRCUMSTANCES OF THE DEATH On the 21st March 2016 the deceased, who was known to misuse Cocaine, was found in a collapsed and unresponsive condition in the bedroom at his home address at 8 Avondale Street, Standish, Wigan. 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. During the inquest evidence was heard that: 1 i. Mr Grimes suffered with schizophrenia and was under the care of the Mental Health Services. Since 2004 he had been supported in the community by support workers from Next Stage which is a home health care service. They provided assistance to Mr Grimes on a daily basis, Monday to Friday. They would attend at his home address to assist him with basic activities and monitor his mental health. If there was a deterioration in his mental health they would contact the appropriate service to ensure Mr Grimes was assessed and provided with treatment as required. ii. On Thursday 17th March 2016 a support worker attended upon Mr Grimes and noted that he was not himself. At that time, he disclosed to her that he had taken an excessive dose of his prescribed medication. A note was made of this disclosure but no action was taken following that information being provided to the support worker. iii. iv. v. The following day, Friday 18th March, another support worker, attended upon Mr Grimes at about 10am, when he again disclosed that he had taken an overdose of his Procyclidine medication, explaining he had taken 12 tablets. At that time, called Wigan Recovery North, the Community Mental Health Team which is governed by 5 Borough Partnerships NHS Foundation Trust, to speak to a Community Psychiatric Nurse (CPN), to report that Mr Grimes had taken excessive medication. requesting A message was left on an answerphone by a call back and explaining that Mr Grimes had taken an overdose of medication. No return call was made to nor was any further call made to Wigan Recovery North by employees at Next Stage to follow up the initial message left. Mr Grimes did not have any contact with anyone after Friday 18th March and was found dead at his home address on Monday 21st March. Evidence was given that if a service user discloses they have taken an overdose of medication to a support worker from Next Stage, that support worker should then speak to a CPN from Wigan Recovery North, if the disclosure is made during their operating hours of 9am to 5pm Monday to Friday. If the disclosure is made out of office hours, Next Stage have an out of hours system where action is taken by the person contacted out of hours to further investigate or manage the service user’s wellbeing. Evidence was given by that there is training that Next Stage offer in respect of how to deal with a report of an overdose by a service user, and other situations that may arise when providing support to a service user, but that he had not had any training in 3 years as his workload did not allow him to undertake confirmed that he felt he, and the other training. employees from Next Stage, would benefit from further training, which could prevent a future death. 2 2. I have concerns with regard to the following: i. ii. That no action was taken by an employee of Next Stage following Mr Grimes’ disclosure of an overdose of medication on Thursday the 17th March. I have further concern that when action was taken on the Friday 18th March, a message was left for the Community Mental Health Team which was not followed up by Next Stage, or answered and actioned by the Community Mental Health Team. Although Mr Grimes’ death was not as a result of an overdose, he did not receive any assessment, or treatment, in respect of the overdose he disclosed. In view of the fact that there was no contact from the Next Stage or the Community Mental Health team over the weekend, he was vulnerable to taking a further overdose of medication. I have concerns that if this situation occurs in the future, another person could die. In view of that I would ask that the current policies and procedures in place at Next Stage to deal with the disclosure of an overdose of medication by a service user, are reviewed, and cascaded down to all employees. I would also request that a review is carried out by 5 Boroughs Partnership of the policies and procedures in place regarding the processing of referrals to Wigan Recovery North given the fact that the message left by on the Friday morning was never acted upon, as if this were to happen again in the future I believe there could be a further death. 6 ACTION SHOULD BE TAKEN In my opinion urgent 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, 20th September 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: (1) , Mr Grimes’ mother on behalf of the family I am also under a duty to send the Chief Coroner a copy of your response. 3 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 Dated Signed 26th July 2016 Rachael C Griffin 4
2 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.
5 Boroughs Partnership INHS| NHS Foundation Trust Our Ref: Chief Executives Office Hollins Park Hospital Your Ref: Winwick Warrington Cheshire WA2 8WA 21 September 2016 Tel: 01925 664001 Fax: 01925 664052 PRIVATE AND CONFIDENTIAL Email: Mrs R C Griffin HM Assistant Coroner Great Manchester (West) HM Coroners Court Paderborn House Civic Centre Howell Croft North Bolton BL1 1JW Dear Mrs Griffin Re: Lee Francis Grimes — deceased Thank you for your letter of 26 July 2016 regarding your findings at the inquest into the death of Lee Francis Grimes on 13 July 2016 and the directions given under the Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. In response to your request to review the policies and procedures in place regarding the processing of referrals to Wigan Recovery North, | can confirm that a review of these procedures has been undertaken > = Matron for Quality, in conjunction with the respective team manager This review took the form of examining how messages are received into the team, identifying the person who is responsible for responding to referrals by phone call and how these are recorded. The review found that referrals by phone cail to Wigan Recovery North are received by the team secretary who is responsible to then transfer the call to a Duty Officer. The Duty Officer is a registered mental health nurse who will deal with the referral ensuring appropriate subsequent action is taken. A Support Time and Recovery (STR) worker is also available to support this process and will always liaise with the registered mental health nurse to discuss appropriate actions. Chief Executive: Mr. Simon J. Barber vt Me, ER YA) Trust Headquarters, Hollins Park House, Hollins Lane, Winwick, Warrington, WA2 8WA. . Ws Mini Com Number 01925 664094 Asap If the call is of an urgent nature and both Duty Officer and STR worker are engaged with other clients, the team secretary will immediately transfer the cail to an available registered mental health nurse in order that the matter can be dealt with effectively. However if the caller deems their message as of a less urgent nature, this is logged into the communication message book, which is checked by the Duty Officer regularly throughout the shift. This procedure is well established within the team and ae .:.: satisfied that all staff members were able to describe this in detail and demonstrate awareness of the correct procedure and their subsequent responsibilities in this regard. We note from the evidence presented at the hearing that an answerphone message was left for the team on the morning of Friday 18 March 2016 at approximately 10 am, however it has not been possible to determine where the message was left. Wigan Recovery North does not utilise an answerphone service before 5pm. An answerphone is only utilised and available outside of normal office working hours, i.e. on weekday evenings after 5pm and at weekends. All messages left during these times are reviewed and addressed at the start of the next working day. The Trust has considered the possibility that the worker in this case may have used an incorrect number for the team. In exercising learning from this review, we have ensured that the team’s correct contact details, including the telephone number, has been re-circulated to all our partner agencies and that the lessons learned from this inquest are shared. This learning has also been discussed within The Trust’s Quality and Safety Meeting with the Wigan Borough and the team manager has shared your findings from the inquest with the team directly involved in the care of Mr Grimes. | hope you will find the above information useful in providing assurance that all referrals received by phone into Wigan Recovery North are appropriately dealt with. If | can be of any further assistance or you require further information about the steps the Trust has undertaken, please do not hesitate to contact me. Yours sincerely Chief Nurse, Executive Director of Clinical Operational Services Chief Executive: Mr. Simon J. Barber st htoe, PAYA) Trust Headquarters, Hollins Park House, Hollins Lane, Winwick, Warrington, WA2 8WA WY: Mini Com Number 01925 664094 Cros
MEMBER OF THE a -UKHCA- UNITED KINGDOM HOME CARE ASSOCIATION LIMITED INCORPORATING HOME CARE AND HOME NURSING SERVICES Ms R Griffin HM Coroner’s Court Paderborn House Howell Croft North Bolton BLIIQY Date 8" August 2016 Dear Ms Griffin Ne 2 NEXT p- STAGE “A Way Forward” 28 Manchester Road Westhoughton Lancashire BL5 3Q) RECEIVED Tel: 01942 818569 Fax: 01942 810520 11 AUG 2016 Web: next-stageltd.org.uk LEE FRANCIS GRIMES - DECEASED. Iam responding to your letter dated 26" July 2016 and can confirm the following actions have taken place. e The communications policy has been revised and details easy to follow procedures when effectively communicating a concern about our clients. (policy included) e All staff is trained in this policy and other key policies at their initial induction to the company. e We have a carousel of regular training for all staff. This policy will be added to this and all staff will have continued access to the training provided. e Staffs have always had clear direction about reporting and recording concerns about clients. The member of staff who did not report the concerns on the 17" March 2016 has been dealt with by the company’s disciplinary procedures. Please do not hesitate in contacting me if you require any further information. Kind Regards eM, 7 Sores OY INVESTORS CareQuality MINDFUL ‘ =i We 4,2 IN PEOPLE Qa EMPLOYER Vora x AsagO Company Registration No. 5022820 RECEIVED 11 AUG 2016 Subject: Section: Page No. 1 of 2 Effectively communicating An incident or concern about Issue Date: Last review Date: Service User Jan 2005 1* August 2016 Policy No: OP0126 Policy Scope: Approv A All Services Service Manager This policy should be read in conjunction with our Adult Safeguarding policy No OP0010 and Data Protection policy No. OP0043. Staff will witness and be privilege to incidents and information regarding our clients on a daily basis. Most interaction and information will be positive and have a positive impact on the individual’s life. Positive changes and achievements need to be recorded and shared where appropriate. Positive outcomes can, with approval be shared with significant others, placing authority and relevant professionals, this course of action should be encouraged. When staff witness or receive information that could be detrimental to the client we need to inform the relevant professional bodies who can advise and assist with helping the client. Information or incidents that need to be reported include: e Any safeguarding concern e Deterioration in health e Drug and alcohol use ¢ Unusual behaviours ¢ Criminal activity e Hospitalisation e Missing This list is not exhaustive; if in any doubt report your concerns immediately to your line manager. It is the responsibility of each member of staff to ensure they have all the relevant professional contact details for their clients including out of hours numbers. PROCEDURE: In the event of a member of staff receiving information they are concerned about or witnessing an incident they are to immediately report it by phone to the relevant professionals involved such as the clients CPN, Social worker, Duty team, you need to make a record of the following: Name of person spoken to Title of this person Contact Number Date and time Conversation held The same information needs to be given to the Registered Manager or in their absence the ‘Senior Service manager by either phone or email. In the event that there is no one available to speak to within the local authority staff are to continue to phone and email their concerns until they have spoken to the relevant person and received instructions from the relevant person within the local authority. This instruction applies to all members of staff within the company. At the first opportunity the staff members gets they are to fill out a detailed incident sheet and hands it to their line manager. When recording information staff are to ensure they record only factual information and include dates, times and names of any individual spoken to. The reporting member of staff will be the main point of contact, when further about the reported incident is received they are to inform their line manager immediately. If a member of staff knows they are going to be absent during an ongoing investigation they are to ensure that their line manager is fully aware and briefed. A simple rule to follow is: if in any doubt report it to the relevant professional body and or your line manager and always follow up with a detailed incident report.
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