Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016 – 0300, written 19 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 | 19 Aug 2016 |
|---|---|
| Reference | 2016 – 0300 |
| Deceased | John Jones |
| Coroner | Mary Hassell |
| Coroner area | Inner North London |
| Category | Community health care and emergency services related deaths · Mental Health related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Regulation 28: Prevention of Future Deaths report
John Richard William JONES (died 18.06.16)
THIS REPORT IS BEING SENT TO:
1. Mr Martin Thomas
Chief Executive
Nightingale Hospital
11-19 Lisson Grove
London NW1 6SH
2.
Consultant Psychiatrist
Keats House Consulting Rooms
24-26 St Thomas Street
London SE1 9RS
1
CORONER
I am: Coroner ME Hassell
Senior Coroner
Inner North London
St Pancras Coroner’s Court
Camley Street
London N1C 4PP
2
CORONER’S LEGAL POWERS
I make this report under the Coroners and Justice Act 2009,
paragraph 7, Schedule 5, and
The Coroners (Investigations) Regulations 2013,
regulations 28 and 29.
3
INVESTIGATION and INQUEST
On 22 April 2016, one of my assistant coroners, Richard Brittain,
commenced an investigation into the death of John Jones, aged 48
years. The investigation concluded at the end of the inquest yesterday. I
made a determination as follows.
John Jones died instantaneously when he jumped in front of a moving
train at approximately 7am on Monday, 18 April 2016 at West Hampstead
Railway Station. However, the state of his mental health at the time
meant that he lacked the necessary intent to categorise this as suicide.
1
4
CIRCUMSTANCES OF THE DEATH
Mr Jones was a patient of
consultant psychiatrist, who
arranged his admission to the Nightingale Hospital, a private hospital
specialising in mental health, on 22 March 2016. Mr Jones was still being
treated by
at the Nightingale at the time of his death.
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.
I heard at inquest that, during his month long residence at the
Nightingale, Mr Jones declined to engage with any of the 35 hours per
week of group therapy on offer. He did see his consultant psychiatrist for
a one to one session three times a week, and he went for a short walk
with his parents most days.
However, for the majority of his time in hospital, this extremely bright and
able but very unwell man, simply stayed in his room alone.
He engaged with nurses who popped in to see him on a polite but only
ever superficial level. Sometimes he used his computer, but he did not
even come out for meals with the other patients. He had a good appetite,
but asked for meals to be brought to his room, which they were.
This seems a very sub optimal therapeutic environment, most particularly
as Mr Jones’s psychiatrist said that the reason for admitting him to
hospital was to enable him to access the therapy on offer. I appreciate
that Mr Jones himself declined the therapy, but the difficulty he had in
accepting help was surely part and parcel of the reason for this episode
of mental ill health, and had to be addressed.
Whether a patient’s engagement is made a condition of stay at the
hospital, whether it is secured by offering a different form of therapy e.g.
on a one to one basis, or whether there is some other way of ensuring
better treatment, is of course a matter for you.
6
ACTION SHOULD BE TAKEN
In my opinion, action should be taken to prevent future deaths and I
believe that you have the power to take such action.
2
7
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date
of this report, namely by 24 October 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 following.
HHJ Peter Thornton QC, the Chief Coroner of England & Wales
Care Quality Commission for England
Royal College of Psychiatrists
parents of John Jones
, wife of John Jones
I 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
interest. You may make
representations to me, the Senior Coroner, at the time of your response,
about the release or the publication of your response by the Chief
Coroner.
it useful or of
find
9
DATE SIGNED BY SENIOR CORONER
19.08.16
3
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.
ae Nightingale Coroner Ms M E Hassell Senior Coroner Inner North London St Pancras Coroner’s Court Camley Street London N1C 4PP 30" August 2016 Dear Ms Hassell Regulation 28 Report to Prevent Future Deaths following the inquest of Mr John Jones on 18" April 2016 | am writing in response to the concerns raised in your Regulation 28 Report following the inquest held on 18" August 2016. It is acknowledged you concluded that Mr Jones experienced a sub-optimal therapeutic environment by virtue of his unwillingness to participate or engage in the formal therapy programmes that were on offer. However, it is further evidenced that to insist and/or force such engagement as a condition of remaining in hospital would run counter to the guiding principles of the Mental Capacity Act (2005). It is however accepted that this lack of engagement gave the impression that the hospital provided only a superficial level of service which amounted to a sub-optimal therapeutic experience. That is not to say that the regular, thorough consultations between consultant, patient, input from nurses and on occasion family sought to determine a plan of care which was agreed by all, and consented to by the patient throughout his treatment. As per your report and as articulated in the Root Cause Analysis (RCA) provided to you for consideration at the hearing, in future, what engagement there is will better be considered through a more formal multidisciplinary forum. Following which discussions it will be possible to develop [perhaps] more conclusive objectives, rationale and purpose of hospitalisation. As such, all staff engaged in the provision of care and indeed the patient and where appropriate, the family will have the opportunity to input into a more comprehensive decision making forum. During a time of increased distress and disengagement a patient may require increased levels of support to assist engagement whilst reducing the level of distress or lack of participation. Action To be completed by:- 1. Review/reconfigure and formalise the This has been completed MDT meeting for General Psychiatric pallens. | Development and introduction of Pathway to be presented to Care Quality decision-making pathway based on Management Group (CQMG) (September) & information gathered and collated from Medical Advisory Committee (MAC) for MDT discussions including the patient ratification in September 2016. and where appropriate, family members. Signed by: Managing Director / Responsible Individual
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