Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0108, written 15 Mar 2016. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 15 Mar 2016 |
|---|---|
| Reference | 2016-0108 |
| Deceased | Anna Masson |
| Coroner | Grahame Short |
| Coroner area | Hampshire (Central) |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths · Railway 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.
GA Short Senior Coroner for Central Hampshire REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Southern Health NHS Foundation Trust CORONER tam G A Short, Senior Coroner for Central Hampshire 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:/Avww.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http:/Awww.legislation.gov.uk/uksi/2013/1629/part/7/made INVESTIGATION and INQUEST On 19/11/2015 | commenced an investigation into the death of Anna Mary Macfie Masson, aged 67. The investigation concluded at the end of the inquest on 14 March 2016. The conclusion of the inquest was Suicide CIRCUMSTANCES OF THE DEATH | determined that Anna Masson was suffering from depression. On 17 November 2015 she went to Micheldever railway station and at about 09.42 she jumped into the path of a non-stopping fast train passing through the station. She died due to Multiple Injuries 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) | received the Trust’s Root Cause Analysis Report relating to the treatment of routine referrals by general practitioners which disclosed a recently introduced screening pathway process. The evidence showed that screening potential service users is conducted by relatively junior members of staff and my concern is whether this process is robust enough to identify those who need urgent treatment. (2) It was unclear from the evidence given whether the screening pathway applied only to the local community mental health team or across all equivalent teams employed by the Trust. | consider that there should be a consistent practise in all teams. Coroner's Office, Castle Hill, The Castle, Winchester, S023 8UL, Tel 01962-667884 | Fax 01962-667893 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you Southern Health 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 11 May 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 Inter erson: | | have also sent a copy of the report Ne | believe has a proper interest. | 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 15 March 2016 Signature. a lot Senior Coroner for Central Hampshire Coroner's Office, Castle Hill, The Castle, Winchester, SO23 SUL Tel 01962-667884 | Fax 01962-667893
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.
Southern Health | NH iS NS ation Trust Tatchbury Mount ; Calmore 9 May 2016 Southampton S040 2RZ Mr G Short Senior Coroner for Central Hampshire Castle Hill The Castle Winchester $023 8UL Dear Sir Regulation 28 Report — Anna Mary Macfie Masson | write further to the above issued on 15 March 2016, following the conclusion of the inquest into the death of Anna Masson. | note your areas of concerns, which | will address in turn, are as follows: 1. I received the Trust's Root Cause Analysis Report relating to the treatment of routine referrals by general practitioners which disclosed a recently introduced screening pathway process. The evidence showed that screening potential service users is conducted by relatively junior members of staff and my concern is whether this process is robust enough fo identify those who need urgent treatment. As part of the work identified during the investigation into the death of Mrs Masson, and following receipt of the Regulation 28 report the Trust has looked at the screening processes in all Adult Community Mental Health Teams (CMHT) and has identified that there is some variation across the Trust in terms of their screening processes. Consequently we have been working to review the CMHT Standard Operating Procedure (SOP) to ensure that a standard process is followed consistently across in all teams in the future to ensure the skill and expertise of those staff undertaking the screening is appropriate and that all decisions are agreed via a multi-disciplinary team discussion. Following completion of work to standardise the process we will undertake a randomised audit across the CMHTs to ensure governance around the screening process. We anticipate that this will be completed in September 2016. 2. It was unclear from the evidence given whether the screening pathway applied only to the community mental health team or across all equivalent teams employed by the Trust. | consider there should be a consistent practise in all teams. Trust Headquarters, 7 Sterne Road, Tatchbury Mount, Calmore, Southampton SO40 2RZ | can confirm that the same approach in terms of the screening pathway will apply across all Adult Community Mental Health Teams as they currently already do within Older Persons Mental Health Teams. This process will also give clarity to the expectation as to when a patient will be seen, dependent on the assessment of the referral. The detail of this is below: |. Urgent referrals: Screened within four hours, seen within 24 hours Il, Soon referrals: Screened within 1 day, seen within 10 days lll. Routine referrals: | Screened with 2 days, seen with 7 weeks. Any referrals that are deemed urgent will be sent on to the Acute Mental Health Teams for urgent prioritisation as per the adult mental health pathway. This process was followed with Mrs Masson. Yours sincerely Katrina Percy Chief Executive Enes.
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