Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0032, written 2 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 | 2 Feb 2016 |
|---|---|
| Reference | 2016-0032 |
| Deceased | Michael Valentine |
| Coroner | Andrew Cox |
| Coroner area | Plymouth, Torbay and South Devon |
| Category | Community health care and emergency services related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
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.
ANDREW JAMES COX
Assistant Coroner for Plymouth Torbay and South Devon
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO: Senior Partner, Knowle House Surgery, 4 Meavy Way,
Crownhill, Plymouth
CORONER
lam ANDREW JAMES COX, Assistant Coroner for Plymouth Torbay and South Devon of 1
Derriford Park, Derriford Business Park, Plymouth PL6 5QZ
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//Awww.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7
http//www.legislation.gov.uk/uksi/2013/1629/part/7/made
INVESTIGATION and INQUEST
On 21 September 2015 | commenced an investigation into the death of Michael John Valentine,
46 years of age. The investigation concluded at the end of an inquest on 2 February 2016. The
medical cause of death was recorded as 1 (a) Helium Toxicity and the conclusion was that Mr
Valentine had committed Suicide
CIRCUMSTANCES OF THE DEATH
On 17 August 2015 Mr and separated.
In the early hours of 18 August Mr Valentine posted on line an image of a self-inflicted wound.
The Police were notified. Mr Valentine was taken to a place of safety at Derriford Hospital
pursuant to Section 136 of the Mental Health Act. He underwent a formal assessment and
although distressed and upset was felt not to be suffering from a mental disorder. He was
discharged without follow up.
On 20 August Mr Valentine was seen by one of the GP’s at your Practice She did
not then feel that he was actively suicidal nor did she feel it was necessary to refer him to the
mental health team.
On 27 August EEE spoke again with Mr Valentine who disclosed to her that he was not
eating.
On 2 September your surgery received a letter from Mr Valentine indicating thathe w:
hunger strike. a <0: to him. She also spoke to her colleagues os a
Consultant Psychiatrist.
HR ubmitted an urgent referral for a mental health assessment. To her knowledge at
the time this was not responded to.
On 10 September [EEE spoke to Mr Valentine again. At that point he told her that he had
not eaten for 25 days.
On 14 September Mr Valentine spoke to one ot colleagues.
On 16 September Mr Valentine was found deceased.
3 The Crescent, Plymouth, PL1 3AB
Tel 01752 204 636 | Fax 01752 313297
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) A fax rejecting the request for a mental health assessment wa: ‘o the Surgery.
This was classed as routine and was not brought to the attention ie It was left in a
tray for dealing (filing) but, unfortunately, due to staff absence, this did not come to light until
after the death of Mr Valentine.
(2) After the telephone consultation on 10 September [EEE agreed that it would have
been appropriate to refer Mr Valentine to the Mental Health Team for a second time given his
disclosure that he had not eaten for 25 days.
(3) [EEE told the Court that there had been a significant events meeting which had looked
at the administrative shortcomings in the Surgery. There had been no discussion, however, of
her decision not to re-refer following the 10 September telephone contact. Similarly, there has
been no discussion of what to do where an application for a mental health assessment has been
rejected.
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and | believe you as Senior
Partner of Knowle House Surgery have the power to take such action. While it is a matter for
you to reflect upon you may feel that it would be of benefit to audit post that i now received
routinely into the Surgery. How long is it before this is reviewed by a doctor?
Additionally, you may feel there would be some benefit in arranging a meeting with your
colleagues in Secondary Care to discuss the procedure for rejecting urgent mental health act
assessments. | have written in similar terms to the Medical Director at Plymouth Community
Health Care. At the Inquest indicated that she felt this would be an appropriate
step to take.
Finally, you may feel that it would be sensible to re-consider the circumstances of Mr Valentine’s
death in light of the clinical decisions following the telephone contact on 10 September at a
significant event meeting. | would be grateful if you would send to me a record of that discussion
if you believe it appropriate to hold one.
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report, namely by
29 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
P| copy of my report to the Chief Coroner and to the following Interested Persons
| 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.
Dated 02 February 201
Assistant Coroner fo mouth Torbay and South Devon
3 The Crescent, Plymouth, PL1 3AB
Tel 01752 204 636 | Fax 01752 313297
ANDREW JAMES COX
Assistant Coroner for Plymouth Torbay and South Devon
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO: The Medical Director Livewell South West, Mount
Gould Hospital, Plymouth
CORONER
lam ANDREW JAMES COX, Assistant Coroner for Plymouth Torbay and South Devon of 1
Derriford Park, Derriford Business Park, Plymouth
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/ukpga/2009/25/schedule/5/paragraph/7
htto:/Avww.legisiation.gov.uk/uksi/2013/1629/part/7/made
INVESTIGATION and INQUEST
On 21 September 2015 | commenced an investigation into the death of Michael John Valentine,
46 years of age. The investigation concluded at the end of an inquest on 2 February 2016. The
medical cause of death was recorded as 1 (a) Helium Toxicity and the conclusion was that Mr
Valentine had committed Suicide
CIRCUMSTANCES OF THE DEATH
On 17 August 2015 Mr anc separated.
In the early hours of 18 August Mr Valentine posted on line an image of a self-inflicted wound.
The Police were notified. Mr Valentine was taken to a place of safety at Derriford Hospital
pursuant to Section 136 of the Mental Health Act. He underwent a formal assessment and
although distressed and upset was felt not to be suffering from a mental disorder. He was
discharged without follow up.
On 20 August Mr Valentine was seen by one of the GP’s at your Practice, | She did
not then feel that he was actively suicidal nor did she feel it was necessary to refer him to the
mental health team.
On 27 August {Spoke again with Mr Valentine who disclosed to her that he was not
eating.
On 2 September your surgery received a letter from Mr Valentine indicating thatlhe was going on
hunger strike. ae to him. She also spoke to her colleagues and rT a
Consultant Psychiatrist.
ubmitted an urgent referral for a mental health assessment. To her knowledge at
the time this was not responded to.
On 10 September spoke to Mr Valentine again. At that point he told her that he had
not eaten for 25 days.
On 14 September Mr Valentine spoke to one of colleagues.
On 16 September Mr Valentine was found deceased
3 The Crescent, Plymouth, PL1 3AB
Tel 01752 204 636 | Fax 01752 313297
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) The circumstances in which an urgent application for a mental health act assessment was
rejected and yet did not come to the attention of the relevant GP. | have written separately to the
Senior Partner at the Practice bringing administrative shortcomings at the Surgery to his
attention. At Inquest, however, it was accepted by [EEE that where urgent applications
for assessment are received these should be marked as urgent where they are rejected. This
did not happen. Additionally, it was felt that a telephone call should accompany the rejection to
ensure the doctor is aware that the application has been rejected and the reasons for that
decision.
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and | believe you The Medical
Director have the power to take such action. While it is a matter for you to decide how to
respond, at Inquest, it was felt that there may be merit in a meeting between and
or colleagues to ensure that a robust and reliable system is put in pace.
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report, namely by
29 March 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 ||
lam 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.
Dated 02 February 2!
Signature.
Assistant Coroner for outh Torbay and South Devon
3 The Crescent, Plymouth, PL1 3AB
Tel 01752 204 636 | Fax 01752 313297
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.
~ Knowle House Surgery Tamerton Surgery 4 Meavy Way Harwood Avenue Crownhill Tamerton Foliot Plymouth Plymouth Devon PL5 3JB Devon PLS 4NU Tel: 01752 705090 Knowle House Surgery Tel: 01752 775470 Fax: 01752 754600 Fax: 01752 759992 22"4 March 2016 Private & Confidential Mr A Cox Assistant Coroner Plymouth. Torbay and South Devon 1 Derriford Park Derriford ‘3usiness Park Plymouth PL6 5QZ Dear Mr ( ox Ref: Reg.alation 28 report to Prevent Future Deaths. Patient: “ir Michael John Valentine dob: 26.03.69 dod: 16.09.15. Thank yo.i for your letter dated 3 February 2016 addressed to Dr Hall. Dr Hall has passed your correspondence to me as the person best suited in the Practice to arrange the actions to be taken. An audit of post was taken on 23/2/16. 235 pieces of correspondence were referred on this day. 216 were distributed to the GPs working that day. 1 GP does not routinely work that day and 19 pieces of correspondence were reviewed by the Duty Doctor for urgency and 18 pieces of correspondence were deemed safe to leave for the doctors return one day later. A re-audi: was undertaken on 22/3/16. 209 pieces of correspondence were received on this day. 175 were distributed to the GPs working that day. 2 GPs were not working that day 100% (34) of their correspondence was reviewed by the Duty Doctor for safety and 33 pieces of correspondence were deemed safe to wait for the GPs to return to review. On balance we are happy that we now have robust procedures for reviewing post and electronic communication within the Practice to keep our patients safe. We met with our Secondary Care Psychiatry colleagues on 18"" March 2016 and discussed the rejection },rocess as well as carrying out a Significant Event analysis on Mr Valentine’s death. I enclose copy of the minutes and outcomes of that meeting. Yours sincerely Practice Manager f RECEIVED "AMAR 2. CORONER'S OFFICE that although this referral was urgent due to the hunger strike they did not feel that this required an immediate response due to the time it would take to carry out his stated action. The Psychiatric Team present maintained that they felt that a physical assessment was still appropriate at this time. It was discussed between the parties that any urgent referrals rejected should be phoned through to the surgery and this should be confirmed by DRSS as Mental Health Services triage referrals on their behalf. In this case Dr Lindsay stated that she felt apprehensive about going to the house alone to visit Mr Valentine and that she knew the MH Team would approach him in pairs and would be able to assess his capacity. Qutcome: After discussion it was confirmed that the referral requested was a Mental Capacity Assessment and not a Mental Health Act Assessment. Although the referral was put through as urgent the fact that he was on hunger strike meant that his suicide was likely to be slow and the request for a physical health examination was reasonable. Due to his past history and mental health problems perhaps ‘alarm bells’ should have rung. Mental 1ealth offered him an appointment but it is not clear why they did not follow him up after a second shone call to him. The rejuction was not phoned through to the surgery meaning the GP did not have this information until a r2w days later and did not follow up the referral believing the Mental Health Team had seen him. It was « greed that both parties would write to the head of DRSS and request the review of their procedures so all urgent mental health referrals that are rejected are telephoned through to the requesting GP as well as rejected through electronic communication (Choose & Book).
; + Livewell Southwest Dr M Cooper PRIVATE AND CONFIDENTIAL Clinical Director H M Coroner’s Office Glenbourne Unit 1 Derriford Business Park Morlaix Drive Derriford Park Derriford PLYMOUTH PLYMOUTH PL6 5QZ PL6 SAF T. (01752) 434838 www.livewellsouthwest.com Our ref: MC/ab 21 March 2016 Dear Sir | am writing in response to your letter sent to our Medical Director. In order to progress this we have had a meeting with Senior Management of Livewell South West and myself as Clinical Director of Adult Mental Health and have reviewed the case. We have reviewed the process of urgent referrals. We note that Knowle House Surgery considered this as part of their Significant Event Process and we met with the practice on Friday 18" March. We understand that the practice will forward a record of the meeting to you. Our actions are as follow: 1. In future any staff that reject an urgent referral will be contacting the referrer direct to confirm the outcome of their assessment of the referral. 2. Wewill also continue with our usual practice that Devon Referral Support Services (DRSS) will notify the referrer, in writing, of any referrals not accepted. 3. We will be seeking advice from the Local Medical Committee to ask how learning can be shared throughout the Primary Care arena and Secondary Care arena. On a matter of accuracy, the request for an assessment from the North Community Mental Health Team was a request for a Mental Health assessment, not a Mental Health Act assessment, which would be a different process. With all best wishes Yours sincerely Mbyte . Dr M Cooper Clinical Director Livewell Southwest Supporting people to be Safe, Well and at Home Livewell Southwest is a trading name of Plymouth Community Healthcare CIC. Company Registration Number 07584107. Registered in England and Wales. Registered Office Local Care Centre, 200 Mount Gould Road, Plymouth. PL4 7PY.
See every Prevention of Future Deaths report matching Community health care and emergency services related deaths, 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.