Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016 – 0278, written 1 Aug 2016. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 1 Aug 2016 |
|---|---|
| Reference | 2016 – 0278 |
| Deceased | Joshua Knox-Hooke |
| Coroner | Nadia Persaud |
| Coroner area | London Greater (East) |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | North Middlesex University Hospital NHS Trust |
| 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.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Elizabeth McManus, Chief Executive, North Middlesex University Hospital NHS Trust, Sterling Way, London, N18 1QX 1 | CORONER | am Nadia Persaud, Senior Coroner for the area of Eastern Area of Greater London 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. http://www.legislation.gov.uk/uksi/2013/1629/part/7/made 3 | INVESTIGATION and INQUEST On the 2" January 2015 an investigation was commenced in the death of Joshua Knox- Hooke. The investigation concluded at the end of the Inquest on the 28" July 2016. The conclusion of the Inquest was a narrative conclusion: Joshua Knox-Hooke was taken by ambulance to A & E at North Middlesex Hospital on the 1' December 2014. He had lacerated his neck and wrist and reported that he had wanted to kill himself. A & E staff were aware of the history of psychosis and recent drug use. Despite this presentation he was not kept within eyesight pending a psychiatric assessment. He left the hospital before a psychiatric assessment was carried out. He was not seen or heard from until 28" December 2014. On the 28” December 2014 he was found deceased partly immersed in the Banbury reservoir. He died as a result of drowning. There was a failure by A & E staff on the 1° December 2014 to comply with the policy in place to ensure that Mr Knox-Hooke should be kept within eyesight of staff at all times. 4 | CIRCUMSTANCES OF THE DEATH Joshua Knox-Hooke was a 22 year old man. He had no history of mental illness prior to 2014. In July 2014, he travelled to Thailand and whilst on his travels suffered an acute psychotic episode. He returned to the UK on the 17" October 2014 where the diagnosis of affective psychotic episode was made. He came under the care of the mental health services provided by Barnet, Enfield and Haringey Mental Health NHS Trust. He was compliant with his mental health care and attended appointments as required with psychiatrists, care co-ordinator and psychologist. He was also compliant with medication. On the evening of the 30" November 2014, Joshua left home and told his brother that he wanted to die. He returned at 05:30 on the 1** December 2014 and during the morning of the 1*' December 2014 he used a kitchen knife to cut both sides of his neck and wrist. He was taken by ambulance to the North Middlesex Hospital A & E. He was triaged by a nurse who noted that he had smoked crack cocaine the previous night and on returning home had cut himself with a kitchen knife causing lacerations to both sides of his neck and wrist. The paramedic staff handed over that Mr Knox-Hooke suffered from psychosis. They also handed over that when asked he stated that he wanted to kill himself. Mr Knox-Hooke also responded to a question by A & E staff to confirm that he wanted to kill himself. Mr Knox-Hooke was taken to the mental health bay. The triage nurse later saw him walking towards the x-ray department / exit. She asked where he was going. He said that he wanted a drink of water and she escorted him back to the cubicle and provided a cup of water. No steps were taken to ensure that Joshua was kept within eyesight at all times. He was captured on CCTV leaving the hospital at 11:38. There is no evidence available to suggest that he was seen leaving the hospital by any member of staff. There is no evidence to suggest that he was encouraged to remain within the unit or to expedite the psychiatric assessment. 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. — My findings of fact included the following:- 1. | was informed that the Trust policy in place in December 2014 required a patient presenting with a current attempt at self-harm and suspected drug use to be nursed in an observable area AND to be kept within eyesight at all times. The evidence revealed that Joshua was not kept within eyesight at all times. 2. The evidence revealed that it is common for patients to leave the North Middlesex A & E prior to psychiatric assessment. This was confirmed by the triage nurse in her oral evidence and also stated within the Root Cause Analysis Investigation Report of Barnet, Enfield and Haringey Mental Health NHS Trust. 3. The triage nurse who gave evidence during the course of the Inquest did not consider that it would be possible to make a patient to remain within the hospital for their own safety. She was unaware of the nurses holding power under Section 5.4 of the Mental Health Act. 4. The North Middlesex University Hospital NHS Trust did not consider this matter to fall within their criteria for a Serious Incident. No Serious Incident Investigation was carried out. 5. The consultant psychiatrist who gave evidence at the Inquest. Hearing confirmed that had Joshua been referred to him on the morning of the 1' December 2014, the presentation at that time would have resulted in him being admitted to hospital (with or without his consent). ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you 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 the 26'" September 2016. |, 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, (mother of Mr Knox-Hooke) and to the CQC. | have also Pe copied the report to the relevant Director of Public Health | 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. 1° August 2016 [SIGNED BY CORONER] —_ nr |-~
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.
North Middlesex University Hospital INHS| NHS Trust Chief Executive Office Trust Headquarters Sterling Way London N18 1QX 161205/Persaud-Knox Hooke/EM/dem 5 December 2016 RECEIVED 8- DEC. 2016 Ms Nadia Persaud Senior Coroner Walthamstow Coroner’s Court Queens Road London E17 8QP Dear Ms Persaud Inquest Touching Upon the Death of Joshua Knox-Hooke, Regulation 28 Report Please accept my apologies for the delay in providing you with the Trust’s response to your Regulation 28 Report following your Inquest touching upon the death of Joshua Knox-Hooke. Following receipt of the prevention of future deaths report from HM Coroner, the Trust has put in place an action plan to improve the safety of mental health patients in the Emergency Department. A copy of this action plan is enclosed. In summary, Mr Knox-Hooke was able to leave the Emergency Department whilst he awaited psychiatric assessment at a time when he was not being observed. The Trust does not provide mental health services and these services are provided on site, in the Emergency Department, by Barnet, Enfield & Haringey Mental Health Trust. In order to reduce the risk of high risk mental health patients leaving the department before they are assessed, the Trust has implemented action to reduce the waiting time for assessment for these patients. The Trust has also implemented a Mental Health Triage Form (MHTF) and prioritisation tool, a copy of which is enclosed. This tool has improved the identification of mental health risk factors at triage and enables high risk patient to be systematically identified so that their mental health assessment is prioritised. Prior to the introduction of the MHTF, the standard was that all mental health patients, regardless of risk, were to be assessed within an hour. Following the introduction of the mental health triage form, all high risk patients are now prioritised for assessment by the mental health team. The training and support for front line clinical staff in the use of the MHTF has been led by the ED Matron. She is using Mr Knox-Hooke’s death in the training programme as a case study to reinforce the importance of the MHTF and timely assessment of high risk patients to illustrate the risks and potential consequences of failing to identify high risk patients who are subsequently able to leave the ED without having been properly assessed. AB MOY, Of 04 i ei R05, Wy, Putting people first sage Chair John Carrier Chief Executive Elizabeth McManus Patients who are deemed to be high risk are admitted to the mental health room and are allocated a 1:1 nurse and security officer to observe the patient awaiting assessment. A video feed of the mental health room is also transmitted to the nurses’ station in area 1 (Majors) in the ED. The ED Matron is currently developing a standard operating procedure so that when patients want to leave the department, prior to assessment, and cannot be deterred or dissuaded from leaving, this is escalated to the nurse in charge and the Police immediately informed. The Trust notes that you explicitly identified the fact that the triage nurse caring for Mr Knox-Hooke in ED was unaware of the nurses holding power under section 5.4 of the Mental Health Act, as a matter of concern. The Trust also notes, however, that the holding power afforded by the Mental Health Act is only to be exercised by a registered mental health nurse who has had appropriate training. The Trust is not a provider of mental health services and this service is provided on site by Barnet, Enfield & Haringey Mental Health Trust. Therefore North Middlesex University Hospital NHS Trust does not employ registered mental health nurses with the authority to detain patients under section 5.4 of the mental health act. The Trust is confident that the actions outlined above, specifically the introduction of the MHTF, will ensure high risk mental health patients are appropriately identified and assessed in a timely manner so as to reduce the risk of such patients absconding prior to assessment in future. However, the Trust has also explored whether Barnet, Enfield & Haringey Mental Health Trust are able to provide a registered mental health nurse, capable of exercising the holding powers afforded by section 5.4 of the mental health act, at short notice at times when it is not possible for a patient identified as being high risk of being appropriately assessed within the specified time. In instances where BEH MHT cannot provide sufficient RMN support to the ED, the ED attempts to book agency RMN staff at short notice. Finally the Trust notes your criticism that the Trust did not consider the patient’s death to be a Serious Incident and did not undertake a Serious Incident Investigation. The Trust was disappointed with this criticism as North Middlesex Hospital was not informed by Barnet, Enfield & Haringey Mental Health Trust that this patient had been found dead, nor was North Middlesex University Hospital NHS Trust invited to participate in the BEH MHT serious incident investigation as it would expect to be given the circumstances. As a result, our Medical Director has discussed this with the Medical Director at BEH MHT so that future serious incident investigations undertaken by BEH MHT that involve aspects of care provided by North Middlesex Hospital undergo a joint investigation in line with the expectations set out in NHS England’s Serious Incidents Requiring Investigation Framework. A new incident management pathway has subsequently been agreed with the BEH MHT clinical lead for North Middlesex Hospital. The Trust has subsequently undertaken its own Serious Incident investigation into Mr Knox-Hooke’s death by reviewing the original Serious Incident investigation undertaken by Barnet, Enfield & Haringey Mental Health Trust and ensuring it captures learning for North Middlesex Hospital. If you require any further information in respect to the Trust’s ongoing response to the prevention of future deaths report received in relation to the inquest into Mr Knox-Hooke’s death, please do not hesitate to contact me. Yours sincerely EWM Elizabeth McManus Chief Executive Encs \3 ABoy, “bn oe SY & x say ROS/7, Putting people first Chair John Carrier Chief Executive Elizabeth McManus
See every Prevention of Future Deaths report matching North Middlesex University Hospital NHS Trust, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.