Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0029, written 1 Feb 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 Feb 2016 |
|---|---|
| Reference | 2016-0029 |
| Deceased | Lorraine Youngs |
| Coroner | David Osborne |
| Coroner area | Norfolk |
| Category | Community health care and emergency services 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.
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 /S BEING SENT TO: Director of Community Services — Adult Social Care Norfolk County Council County Hall Martineau Lane Norwich NR1 2DH 1 | CORONER | am DAVID OSBORNE, Assistant Coroner, for the coroner area of NORFOLK 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 27 March 2015, an investigation was commenced into the death of LORRAINE © SHEILA YOUNGS aged 35 years. The investigation concluded at the end of the inquest on 27 January 2016. The conclusion of the inquest which was held before a jury was that she killed herself by a deliberate act but it is unclear if she intended to kill herself. The medical cause of death was 1a: Hanging. 4 | CIRCUMSTANCES OF THE DEATH At the time of her death Lorraine Young’s was a detained patient at Hellesdon Hospital. She was discovered on 24 March 2015, unresponsive in the public pay phone room on the ward having wrapped the telephone cord around her neck. A pulse was regained but she sadly died at Norfolk and Norwich Hospital 2 days later. 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. — The inquest heard evidence regarding Lorraine Young's care in the community. Evidence was given from Lorraine's social worker that a care package had been agreed in principle at a visit on 12 February 2015. At the time of her death, this had not been implemented. The evidence given was that this had not been followed up. Whilst it could not be said in the context of Lorraine's death whether the delay affected the outcome, | was concerned that a delay in following up implementation of an agreed care package could, in different circumstances, affect the outcome for.a vulnerable Service User. The evidence before the inquest was that there appeared to be no system for following up implementation of an agreed care package. 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 duly to respond to this report within 56 days of the date of this report, namely by 28 March 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 | have sent a copy of my report to the Chief Coroner and to the following Interested Persons: : Ihave also sent it to The Department of Health The CQC ; Norfolk Gounty Council - Democratic Services Heaithwatch Norfolk who may find it useful or of interest. 1 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 February 2016 POE Ye eile terttterreerens em David Osborne Assistant Coroner for Norfolk
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.
: | Ad It Social Servi 8s Norfolk County Council at Soc Floor County Hall . NORWICH, NR1 2DH Private and confidential . Mr David Osborne . Tel: 01603 223960 HM Assistant Coroner . Fax; 01603 223096. 69 — 75 Thorpe Road : . Norwich Norfolk : NR‘ 1UA ; O a - Qur ref: LB/MWI/LY-Reg28 Date: 29 March 2016 Dear Sir ‘Re: Lorraine Youngs of Flat 51, Foulgers Opening, Norwich NR1 3AH - D.O.B 05/02/1980 Inquest date: 26/01/2016 to 27/01/2016 ; ; . I refer to the Regulation 28 Report to prevent Future Deaths dated 4 4 February 2016 issued to Mr Harold Bodmer, Executive Director of Adult Social Services, Norfolk County Council. | should be grateful if you would accept this [etter as providing the response to this report. : The Report identified the following matters of concern: “The Inquest heard evidence regarding Lorraine Young's care in the community. Evidence was given from Lorraine's social worker that a care package had been agreed in principle at a visit on ’ 42 February 2015. At the time of her death, this had not been implemented. The evidence given was that this had not been followed up. Whilst it could not be said in the context of Lorraine's ’ death whether the delay affected the.oufcome, |! was concemed that a delay in following up implementation of an agreed package could, in different circumstances, affect the outcome for a vulnerable service user. The evidence before the inquest was that there appeared to be no system for following up implementation of an agreed care package.” The response from the local authority is as follows: At the time of this serious incident in March 2015, social. work support to patients in the acute © wards at Hellesdon Hospital was provided by the responsible locality mental health social care team. The team responsible for assessment and commissioning social care services for LY was the Norwich locality mental health social care team based at Gateway House, Wymondham. In May 2015, Norfolk County Council (NCC) made changes to the social care support atrangements to the wards at Hellesdon Hospital. The wards are now served by a dédicated Hospital Discharge Social Care team based on the Hellesdon Hospital site. ‘www. norfolk.gov.uk Three experienced mental health social worker/Approved Mental Health Professionals based in this team link with the acute wards to ensure early signposting, timely and proportionate needs assessments, multi-disciplinary decision making and discharge planning. This facilitates much closer working arrangements which ensure that patients who are admitted to the ward can be ‘assessed as soon as they are well enough, and arrangements made for their discharge. This means that delays and last minute arrangements are avoided. The Hospital Discharge Social Care staff cover for one another during any period of absence to ensure that agreed actions are followed up. There is also the back-up of the North. locality mental health team duty system, whereby there is a member of staff available every day during office hours to respond to urgent and unplanned requests. The Hospital Discharge Social Care team is managed by a Practice Gonsultant (Senior Social Worker) and Team Manager who are also based on the Hellesdon Hospital site. The social care staff in this team receive formal monthly supervision. The Hospital Discharge Social Care feam can refer people to Norfolk First Support if a person has been identified as suitable for re-enablement and may not require care in the longer term. This service provides six weeks re-enablement for people in their own homes, supporting where temporary conditions have reduced the person's ability to care for themselves or to re-enable people to care for themselves as far as they are able e.g. people who have suffered fractures or a short term acute illness. This service can'be arranged at short notice and can support hospital discharge. If the assessment by the hospital discharge social worker indicates longer term needs, the worker instructs the NCC Care Arranging Service to source care services. The Care Arranging Service (CAS) shares the relevant assessment information with the potential care provider to ensure that they are able to meet the person’s assessed care and support needs and identifies the date the care package is needed to start. The actions of the Care Arranging Service are recorded on - CareFirst, the NCC electronic client based Information system. Having this dedicated team ensures that the care requests are followed up and actioned. CAS . keep the social worker informed of their actions and the care they have arranged. If CAS are unable to source the care arid support required they inform the social worker and keep an unmet need log. Once the person is discharged from hospital, the locality social work team becomes’ responsible , for ensuring that the care package continues to meet the needs of the person by carrying out an initial review at four weeks and then at regular intervals. | trust this response answers your concerns but if you have any further queries, please do not hesitate to contact me. . Yours faithfully [yr Beslo Lorna Bright Assistant Director, Social Work www.norfolk.gov.uk
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