Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0114, written 18 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 | 18 Mar 2016 |
|---|---|
| Reference | 2016-0114 |
| Deceased | Jonathan Lander |
| Coroner | Geraint Williams |
| Coroner area | Worcestershire |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Herefordshire and Worcestershire Health and Care NHS Trust |
| 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.
ANNEX A 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 IS BEING SENT TO: 1. Worcestershire Health and Care NHS Trust 3 CORONER | am Geraint Urias Williams, Senior Coroner, for the coroner area of Worcestershire 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. INVESTIGATION and INQUEST On 28” April 2014 | commenced an investigation into the death of Jonathan James LANDER then aged 37 years. The investigation concluded at the end of the inquest on 18 March 2016. The conciusion of the inquest was narrative formulation (copy herewith) the medical cause of death being 1(a) multiple trauma, 2 intoxication by drugs of abuse . CIRCUMSTANCES OF THE DEATH On 28" April 2015 Mr Lander was killed when he was struck by a train on the tracks near to Black Bridge, Worcester Road, Hartlebury. 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) That there is not in place any policy or procedure for the following up of individuals who are seen by one service and thereafter discharged to another service. In the course of the inquest | was provided with a Root Cause Analysis which identified the failing mentioned above and which contained an action plan indicating that such a policy/procedure was to be implemented by September 2015 | was told in the course of the inquest that that policy/procedure has not been implemented. | was left with the sense that this is still to be considered but there appears to be no sense of urgency. | was further told that the Trust has a governance procedure to ensure that action plans are “followed through" but it seems to be clearly the case that this has not worked either. | respectfully suggest that you consider urgently the necessity for a such a procedure / policy and to implement it. (2) (3) ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you 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 16" 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 Interested Persons, Next of Kin. | have also sent it to Swanswell who may find it useful or of 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. GU Williams H M Senior Coroner 18th day of March 2016
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.
¢ ) Helping you live well Worcestershire Health and Care NHS) in Worcestershire NHS Trust Chief Executives Office Worcestershire Health and Care NHS Trust ’ \saac Maddox House Your Ref; W980.15 Shrub Hill Road Worcester Our Ref: SD/GH/LM WR4 9RW Date: 12 May 2016 Tel: 01905 681667 Mr GU Williams emai HM Senior Coroner for the County of Worcestershire www. hacw.nhs.uk Worcestershire Coroner's Court 3 The Civic 194 Os Martins Way “AOD bare Stourport-on-Severn YH Worcestershire DY13 8UN ( iy iy Dear Mr Williams Ay Johnathan James Lander (Deceased) Thank you for your letter dated 22 March 2016 issued pursuant to Regulation 28 of the Coroner's Regulations. Following the inquest the Trust now has in place an agreed Substance Misuse Information Sharing Protocol between itself and Swanswell, Worcestershire Recovery Partnership. | enclose a copy for your ease of reference. The purpose of the protocol is to ensure relevant clinical and other material information is shared where there are concerns regarding a patient's mental health and substance misuse, to ensure that services have up to date information and that patients will receive the appropriate treatment from both agencies. | can advise in relation to a governance procedure to implement the Action Plans set out in individual Root Cause Analyses that the Trust now has an Embedded Lessons Database, All the Action Plans set out in individual Root Cause Analyses are now uploaded to that database together with evidence of completed actions. This database is monitored by the Governance Team based in the Adult Mental Health and Learning Disability Service Delivery Unit. ! note that the issues raised in this case may be of relevance to those providing healthcare services in other Trusts nationally and can see that there may be merit in the Chief Coroner publishing either a summary or redacted form of our correspondence | shall be grateful if you could kindly send a copy of my letter sl | hope the above addresses your concerns, however, if you have any queries do not hesitate to contact me. Enc: Substance Misuse Information Sharing Protocol between Worcestershire Health and Care NHS Trust and Swanswell, Worcestershire Recovery Partnership Chatman: Chris Burdon Chief Executive: Sarah Dugan
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