Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0065, written 19 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 | 19 Feb 2016 |
|---|---|
| Reference | 2016-0065 |
| Deceased | Brenda Morris |
| Coroner | Mary Hassell |
| Coroner area | Inner North London |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths · Suicide (from 2015) |
| Organisation named | East London NHS Foundation Trust |
| 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
Brenda Elizabeth MORRIS (died 20.07.15)
THIS REPORT IS BEING SENT TO:
1.
Medical Director
East London NHS Foundation Trust
Trust Headquarters
9 Alie Street
London E1 8DE
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 July 2015 I commenced an investigation into the death of Brenda
Elizabeth Morris, aged 66 years. The investigation concluded at the end
of the inquest yesterday. I made a determination of suicide, when Ms
Morris drowned herself in the bath at home.
4
CIRCUMSTANCES OF THE DEATH
Approximately three weeks before she died, Ms Morris took an excess of
Oramorph and was taken to hospital. She then went to see her general
practitioner, who was extremely concerned and arranged for immediate
referral to the mental health services. Ms Morris was admitted to Larch
Lodge, where she was treated as an informal patient. She was given
weekend leave in mid July and again on Sunday, 19 July, the day before
she died.
1
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.
1. Brenda Morris was allowed weekend leave on the basis that her
partner was at home to keep an eye on her, but no member of staff
told him this. This was not a situation where she needed 24 hour
supervision Nevertheless, it would have been helpful for him to
know the basis for the leave, because he would then have
modified his own behaviour accordingly.
2. The weekend before the weekend of her death, Ms Morris’s
partner felt that she had not been well during the weekend leave. I
appreciate that care must be taken not to override a patient’s
autonomy, but it might be useful for staff routinely to consider
whether they are able to obtain feedback from family members
after such leave.
3. There appears to be confusion about whether a doctor is needed
to authorise unplanned leave of an informal patient (not relevant in
this case because the leave had already been authorised). Your
serious incident review of this matter indicates that this is
necessary, but I heard evidence that such medical authorisation is
not routinely sought.
4. Substandard documentation in the nursing records had already
been identified before the inquest by your serious incident review.
Without improvement in the records, it is not possible to determine
whether and if so by whom a necessary risk assessment is
undertaken, e.g. immediately before weekend leave is taken.
6
ACTION SHOULD BE TAKEN
In my opinion, action should be taken to prevent future deaths and I
believe that you and your organisation have the power to take such
action.
7
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date
of this report, namely by 16 May 2016. I, the coroner, may extend the
period.
2
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
partner of Brenda Morris
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
interest. You may make
he believes may
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
19.02.16
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.
East London NHS
NHS Foundation Trust
Trust Headquarters.
9 Alie Street
London
E1 8DE
Telephone: 0207 655 4177
Fax: 0207 655 4076
13" May 2016
Senior Coroner M E Hassell
Inner North London
Poplar Coroner’s Court
127 Poplar High Street
London
E14 0AE
Dear Madam
Inquest touching upon the death of Brenda Morris
This is a formal response to your Regulation 28 Report dated 19" February in which you set
out your concerns relating to the care Ms Morris received from East London NHS
Foundation Trust.
Your concerns related to the provision of leave for informal patients. You were specifically
concerned at the lack of information provided to Ms Morris’ partner in relation to her home
leave and his role in facilitating that leave. You were also concerned that staff had not
engaged with Ms Morris’ partner on her return from leave to obtain feedback.
You also highlighted in your report that there appeared to be confusion over whether a
doctor was required to authorise unplanned leave for an informal patient. This concern
stemmed from the evidence given by the ward manager during the Inquest being in conflict
with that detailed in the Trust’s Serious Incident Review.
You also comment on the issue of substandard documentation in the nursing records, noting
that this had already been identified by the Trust prior to the Inquest, noting that without
improvement in the records it is not possible to determine whether and if so by whom a
necessary risk assessment is undertaken immediately before leave is taken.
| can confirm that the information contained in the Trust's Serious Incident Review is correct
in stating that a doctor is required to authorise unplanned leave for an informal patient.
| was concerned to hear the evidence of the ward manager that a doctor is not required to
authorise unplanned leave and that this is not routinely requested. Having heard the
evidence of the ward manager at the Inquest | investigated this issue on my return. | was
able to establish that the understanding of this particular ward manager was not in line with
the general understanding of our nursing staff.
Po Chief Executive: Dr Robert Dolan
However, in light of the importance of this issue the Trust has taken the decision to
implement the use of template documentation to ensure that any leave has been
appropriately agreed by a doctor. A new ‘informal patient leave agreement’ has been
developed. This document details the agreement of leave following assessment by a doctor.
The template includes a box detailing any leave conditions along with any expectations from
staff, patients, relatives and carers. A separate box deals with contingency plans. The
agreement is then signed by the doctor, the patient and the relative. This document is
expected to be in place before a patient goes on leave.
In addition to the above an ‘In-patient leave checklist for informal and detained patients’ has
been developed. It is also a requirement for this checklist to be completed for all leave. The
checklist requires staff to assess risk prior to any period of leave, discuss with family or
friends issues of risk and provide relatives/carers with a copy of an individualised
contingency care plan. On return from leave staff will need to confirm that they have
obtained feedback from family on the patient's return from leave. The detail of all
assessments and discussions will be fully documented on RIO.
When implementing these new templates it is of the utmost important that the Trust strikes
the right balance between appropriate risk assessment and ensuring that informal patients
are able to exercise their right to make decisions in respect of leave and that we work in line
with the views of the CQC that there should be no blanket restrictions on leave for informal
patients.
Both forms are currently being piloted on one of our Mental Health Care for Older Persons
wards with the aim of full introduction across all of our Older Persons wards by the end of
this month. Use of the forms and the corresponding RIO entries will be the subject to
quarterly audits starting from the end of July 2016 until January 2017 and will be subject to
further review thereafter if necessary.
{ fully anticipate that the implementation of these changes will ensure that all patients,
whether formal or informal, will be subject to appropriate assessment prior to any period of
leave and again on their return.
| hope that the actions taken by the Trust in response to your concerns will provide you with
the appropriate reassurance.
If you require any further information please do not hesitate to contact me.
Yours fajthfully
Dr Kevin Cleary
Medical Director
Po Chief Executive: Dr Robert Dolan
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