Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016 – 0275, written 29 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 | 29 Jul 2016 |
|---|---|
| Reference | 2016 – 0275 |
| Deceased | Danny Sweet |
| Coroner | Andrew Cox |
| Coroner area | Cornwall and the Isles of Scilly |
| 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.
ANNEX A
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 P Confue, Chief Executive Cornwall Partnership Foundation Trust,
Fairview House, Corporation Road, Bodmin, Cornwall PL31 1FB.
1 | CORONER
| am Andrew Cox, Her Majesty's Assistant Coroner for the coroner area of Cornwall and
the Isles of Scilly.
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 4 November 2015, an inquest was commenced into the death of Danny Sweet. The
inquest concluded at a hearing on 21 July 2016. The medical cause of death was found
to be:
la Fulminant hepatic failure;
Ib Paracetamol overdose.
Il returned an open conclusion. While | felt it was highly likely that Mr Sweet had taken
his own life and intended to do so, | could not be sure of this.
CIRCUMSTANCES OF THE DEATH
Mr Sweet had a long history of mental health issues extending back nearly 20 years.
On 15 September 2015 he was seen in the Emergency Department at Royal Cornwall
Hospital Truro following a suspected overdose. He was seen by an Consultant
Psychiatrist, who considered whether Mr Sweet should have a Mental Health Act
assessment.
HE oncludea that there were no grounds to detain Mr Sweet compulsorily. He
considered whether a voluntary admission was appropriate, but instead chose to refer Mr
Sweet to the Home Treatment Team.
Mr Sweet was seen the next day by the Home Treatment Team and I heard evidence
from HEE who saw Mr Sweet with a colleague.
Notwithstanding the Consultant's misgivings the day before, EE found Mr Sweet to
be much improved. He felt there was no need for involvement by the HTT and elected to
refer Mr Sweet to the Community Mental Health team.
Mr Sweet was subsequently seen b' on 16 even ' is to say, one
month after the assessment by Mr Sweet told he was much
improved and did not need any input from CMHT. Accordingly EEE discharged
him from the caseload.
Subsequently, Mr Sweet told an out of hours worker that he had nisled and
that, in fact, his true condition was worse than he had led her to believe. A duty worker
subsequently contacted Mr Sweet who, yet again, gave a contrary indication and said
that he did not require any assistance.
On 23 October (one week after discharge from the CMHT workload) Mr Sweet took a
staggered overdose of paracetamol and died the next day in Treliske hospital.
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:
Mr Sweet presented in equivocal and contradictory fashion. Accordingly, he was very
difficult to assess and it was equally difficult for clinicians to form a view of the likely risk
he posed to himself.
| was concerned, however, that the very day after a Consultant Psychiatrist contemplated
informal admission into hospital, a nurse from the HTT felt able to refer Mr Sweet to the
Community Mental Health team where he was not seen for a month.
| wondered if it may be appropriate to reflect on how to deal with patients who present in
an inconsistent manner. In particular, | questioned whether it was appropriate simply to
presume the best case scenario.
| was further concerned whether or not it was appropriate for a check to be built into the
assessment process to ensure consistency in treatment decisions. There appeared to
be obvious inconsistencies first in the concern offfland the decision the very next
day to discharge Mr Sweet from the caseload of the HTT and secondly, in the decision of
ao refer to CMHT yet EEE discharging Mr Sweet from caseload after a
first assessment.
Mr Sweet's case raises a more general issue namely, how the Trust deals with patients
(within the confines of the Law as currently drawn) who appear to have capacity and yet
decline treatment/care even where family/friends state their condition is deteriorating.
| recognise this is a difficult issue. | wonder, however, whether in such situations,
clinicians should record in the notes and records their concerns that patients have
capacity and yet may go on to self-harm. Furthermore, | feel it may be worth reviewing if
clinicians should share those concerns with family/friends who try and bring to attention
the patient’s deteriorating condition. | recognise there will be an obvious need to respect
the rules on confidentiality.
| raise also whether there should be training to ensure that the entrigs ji tes and
records are consistent. By way of illustration, where| and ian ccics to
discharge Mr Sweet from their respective caseloads, they should justify those decisions
in light of s earlier concern that Mr Sweet may need an informal admission into
hospital.
incomplete. In particular, neither nor had been formally interviewed as
part of the review process. You may feel that there would be merit in getting the
respective clinicians from the relevant departments (Hospital Liaison, HTT and CMHT)
together to see if there are any lessons to be learned.
A final matter that came out of the —_ was that the Serious Incident Report was _
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and | believe you (AND/OR
your organisation] have 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 23 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.
COPIES and PUBLICATION
Ihave s f my re jef Coroner and to the following Interested
Persons ind to Solicitor Cornwall Partnership Foundation
Trust.
| 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 Assistant Coroner, at the time of
your response, about the release or the publication of your response by the Chief
Coroner.
[DATE] 2904 {Ib [SIGNED BY CORONER] FP. Klas WW
29 July 2016 AJ COX
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.
Chief Executive’s Office Fairview House Corporation Road Bodmin Cornwall PL31 1FB Tel: 01208 834613 Fax: 01208 269645 23rd September 2016 Mr Andrew J Cox Assistant Coroner for Cornwall and the Isles of Scilly By Email only cornwallcoroner@cornwall.gov.uk Dear Mr Cox Regulation 28 Report to Prevent Future Deaths I refer to your Regulation 28 Report following the inquest of Danny Sweet. As an organisation our vision is “Delivering high quality care” and therefore we welcome the opportunity to reflect not only your concerns but also the evidence given by during the course of the inquest. We have given careful consideration to your report and our response. We view this as a positive opportunity for the Trust to ensure there is learning. We have tried to respond to each matter of concern as outlined in your report and detail the action to be taken. • Is it appropriate to reflect on how to deal with patients who present in an inconsistent manner? Is it appropriate to presume the best case scenario? We agree that it is appropriate to reflect on how to deal with patients who present in an inconsistent manner. It is not appropriate to presume the best case scenario and clinical staff are trained to use structured risk assessments. However we propose to launch a review into the clinical risk assessment of people who present with suicidal thoughts or acts across each of our services and in particular the Trust’s use of the STORM We are a research active trust, to get involved in a research project, please email cpn-tr.CFTresearch@nhs.net For information on mental health medication visit choiceandmedication.org/cornwall Chair: Barbara Vann Chief Executive: Phillip Confue Head Office: Fairview House, Corporation Road, Bodmin, Cornwall, PL31 1FB. Tel: 01208 834600 Email: cpn-tr.enquiries@nhs.net cornwallfoundationtrust.nhs.uk risk assessment as wider learning across the Trust. We hope to have completed the review by the end of February 2017. • Is it appropriate for a check to be built into the assessment process to ensure consistency in treatment decisions It is impossible to ensure consistency in treatment decisions because assessments are “of the moment” and there has to be flexibility for clinicians as situations can change. However, the Trust does recognise that there does need to be a clearly defined pathway decided at the initial presentation. The action that will be taken is that there will be a Learning from Experience meeting. We will ensure that clinical staff, across all services involved in the care of Mr Sweet, participate in the meeting. The meeting will be overseen by Inpatient Clinical Director and Consultant in Rehabilitation Psychiatry. One of the purposes of the meeting will be to consider developing the pathway. • How the Trust deals with patients who appear to have capacity and yet decline treatment/care where family/friends state their condition is deteriorating. The Mental Health Act provides the legal framework to deal with patients who have capacity yet decline treatment. In light of your report and Mrs Sweet’s witness statement the Trust acknowledges the need for staff to engage with family and friends in receiving information from them as well as building on the work undertaken by the Trust around the “triangle of care.” The aim would be to ensure that not only are family and friends supported but also informed about services and mental health and involved in the care provided. We recognise the importance of staff engaging with friends and family in their assessments and on-going care. It will be a further purpose of the Learning from Experience Meeting to consider ways of doing this. • Should clinicians record in the records their concerns that patients have capacity and yet may go on to self-harm? It may be worth reviewing if clinicians should share those concerns with family/friends who try and bring to attention the patient’s deteriorating condition. • Should there be training to ensure that the entries in the notes and records are consistent. The Trust does provide training to staff in relation to record keeping and the importance of recording the rationale for decisions. We are already enhancing the record keeping of staff by implementing the “SBAR” (Situation, Background, Assessment, Recommendation) tool as standard in record keeping. This has been introduced to staff on our psychiatric inpatient wards and we will continue to filter this through across all services. We are therefore making efforts and taking action to introduce a more structured format to our records. This action is on-going. • The Trust’s Serious Incident report is incomplete. The Trust acknowledges that the Serious Incident Report is incomplete. There are learning points for the Trust in relation to Serious Incident Investigations and the Trust’s Director of Quality and Governance/Executive Nurse, will take this forward. We will ensure that in the future all key clinicians, within the Terms of Reference, are involved in future investigations. We have also identified the importance of providing feedback to staff interviewed for the purposes of the investigation. Page 2 In summary there will be action taken by the Trust by way of a Learning from Experience Meeting to consider ways of developing a pathway; how to engage friends and family and to allow a further period of reflection. It is expected that an action plan will be developed at the Learning from Experience meeting. There will also be a review of the clinical risk assessments of people who present with suicidal thoughts or acts by the end of February 2017 and we will review the Trust’s Serious Investigation process. The Trust is truly saddened by the death of Mr Sweet and wish to extend our condolences to his family. Yours sincerely Phil Confue Chief Executive Page 3
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