Joyce Carney

Date of report	7 Apr 2016
Reference	2016-0140
Deceased	Joyce Carney
Coroner	Alan Walsh
Coroner area	Manchester (West)
Category	Hospital Death (Clinical Procedures and medical management) related deaths
Organisation named	Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation Trust
Source	judiciary.uk record · original PDF
Responses published	3

The report

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.

REG

ULATION 28: REPORT TO PREVENT FUTURE DEATHS (1)

NOTE: This form is to be used after an Inquest.

3 | INVESTIGATION and INQUEST

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:

1. Rt Hon Teresa May, Home Secretary, The Home Office, 2 Marsham
Street, London SW1P 4DF

2. Rt Hon Jeremy Hunt, Secretary of State for Health, Department of
Health, Richmond House, 79 Whitehall, London SW1A 2NS

3. Mr Andrew Foster, Chief Executive, Wrightington Wigan & Leigh NHS
Foundation Trust, Royal Albert Edward Infirmary, Wigan Lane, Wigan
WN1 2NN

4. Mr Ian Hopkins, Chief Constable, Greater Manchester Police, Central
Park, Northampton Road, Manchester M40 5BP

CORONER

Tam Alan Peter Walsh, HM Area Coroner for the Coroner Area of Manchester
West

CORONER'S LEGAL POWERS

I 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.

On the 16" February 2015 I commenced an investigation into the death of
Joyce Carney, 81 years, born 8th February 1934. The investigation concluded
at the end of the Inquest on 23 March 2016.

The medical cause of death was

la Acute Bronchitis, Renal Failure and General Debility

ib A combination of fractured neck of femur (operated), insulin dependant
Diabetes, Myocardial Scarring and Vascular Dementia

The conclusion of the Inquest was Joyce Carney died as a consequence of a
combination of naturally occurring disease and injuries, together with the
treatment of the injuries, sustained when she was knocked to the floor in the
corridor of a hospital by another patient, who was running away from Police
Officers in an attempt to leave the hospital.

a

CIRCUMSTANCES OF THE DEATH

1. Joyce Carney (hereinafter referred to as “the Deceased”) died at the
Royal Albert Edward Infirmary Wigan on 11" February 2015.

On the 20" December 2014 the Deceased, who was known to suffer
with naturally occurring Insulin Dependent Diabetes Mellitus and
Dementia, was admitted to the Royal Albert Edward Infirmary, Wigan
with low blood sugars, Acute Kidney Injury and Urinary Tract Infection.
She was transferred from the Emergency Department at the Hospital to
Lowton Ward in the Hospital later the same day.

On the 21* December 2014 another Patient (hereinafter referred to as
“the Patient”) was admitted to Lowton Ward at the Hospital under the
observation of Police Officers pending a Mental Health Assessment but
the Patient was not under arrest by the Officers, although the Officers
were under instructions to arrest the Patient if he attempted to leave the
Hospital.

At or about 20.40 hours on the 21 December 2014 the Deceased went
to the toilet, which was situated off a corridor on Lowton Ward at the
Hospital and, shortly after leaving the toilet, the Deceased was knocked
to the floor in the corridor when the Patient, who was being observed by
the Police Officers, collided with her whilst running away from the
Officers and attempting to leave the Hospital.

The Deceased sustained a fractured neck of femur when she was
knocked to the floor and she had surgery to repair the fracture on the
24" December 2014, after which she suffered with chest and urinary
tract infections treated with antibiotics. She deteriorated on the 9"
February 2015 and she died on the 11" February 2015.

_

ONER’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.

During the Inquest evidence was heard that:-

i. | When the Patient was moved to Lowton Ward in the Hospital the
risk assessment conducted by the Hospital in relation to the
location of the Patient in the Ward involved the Bed Manager, the
Ward Manager and the Nurses treating the Patient. The risk
assessment did not involve, nor include, the Police Officers who
were observing a patient. The risk assessment conducted by the
Hospital focussed on the safety of the Patient and did not extend to
the safety of other patients in the Hospital, visitors to the Hospital,
members of the public and members of staff employed in the
Hospital.

ii. The tisk assessment conducted by Police Officers, in relation to the
Patient at the Hospital, focussed on the Patient and the fact that

the Patient may seek to leave the Hospital but the assessment did
not include any discussions or liaison with Hospital staff. The risk
assessment did not include the protection of other patients in the
Hospital, visitors to the Hospital, members of the public or staff
employed in the Hospital.

There was no liaison or communication between the Police Officers
observing the Patient and the Hospital treating the Patient in
relation to the layout of the Hospital or with regard to the safety of
other patients in the Hospital, visitors to the Hospital, members of
the public and staff employed in the Hospital.

The lack of liaison led to Police Officers believing that a fire escape
existed at the end of Lowton Ward and to the side of the Patient’s
bed, which had to be protected to prevent the Patient leaving the
Hospital. The Officers believed that the fire escape involved a 20 to
30 foot drop from the 2" floor of the Hospital onto an open area
outside the Hospital building, which could be used to leave the
Hospital or to commit self-harm. In fact the evidence at the Inquest
established that the fire escape was not a fire escape but simply a
fire exit into a corridor leading into another Ward within the
Hospital without any exit door or exit from the building. Focus upon
the fire exit and a belief that there was an exit in the corridor led to
the Police Officers making a decision to sit on one side of the
Patent's bed, and at the foot of the bed, leaving the side of the bed
facing the exit to the Ward open for the patient to leave the
Hospital.

Furthermore the Officers at the Hospital raised concerns with their
Supervising Officer, namely a Sergeant at the Police Station, in
relation to the Patient being agitated and threatening to leave the
Hospital during the afternoon of the 21% December 2014 but
neither the Sargent nor any other senior Officer attended the
Hospital to conduct any further risk assessment or to reassess the
situation.

There are no agreed protocols, policies or procedures between the
Greater Manchester Police and the Royal Albert Edward Infirmary,
Wigan in relation to joint risk assessments for patients detained at
the Hospital under arrest or in the presence of or supervised by
Police Officers. Furthermore there is no protocol, in relation to
liaison and consultation between the Greater Manchester Police and
the Hospital to formulate risk assessments in relation to patients
detained at the Hospital under arrest or in the presence of or
supervised by Police Officers.

During the course of the evidence it was accepted that risk
assessments conducted by either the Police or the Hospital, and any
joint risk assessments, should focus upon the Patient but the
assessments should also include the protection of other patients in
the Hospital, visitors to the Hospital, members of the public and
staff employed in the Hospital.

v. The evidence at the Inquest indicated that the absence of
protocols, policies and procedures in relation to joint risk
assessments as between the Police and Hospitals is likely to arise in
relation to the detention of patients in many Hospitals in the United
Kingdom where patients are detained under arrest or in the
presence of or supervised by Police Officers.

vi. The evidence at the Inquest accepted that, if the Patient had not
been able to attempt to leave the Ward in the Hospital, the
Deceased would not have suffered the injury, which contributed, to
the cause of her death.

vii. At the Inquest it was accepted by the Police and the Hospital that
patients are taken to the Royal Albert Edward Infirmary, Wigan on
a weekly basis under arrest or in the presence of or supervised by
Police Officers and on many occasions a patient, in the presence of
the Police, is admitted to a Ward in the Hospital from the
Emergency Department. Accordingly, a risk assessment in relation
to the location of a patient in the presence of the Police, either in
the Emergency Department or in a Ward, is an important factor in
risk assessments to protect other patients in the Hospital, visitors to
the Hospital, members of the public and staff employed in the
Hospital, particularly if the patient is known to be violent or the
patient has a previous history of sexual offences. Such matters may
only be within the knowledge of the Police and liaison between the
Hospital and the Police is critical to enable such information to be
considered within the risk assessment and to enable the Police to
be aware of the layout of the Hospital.

viii. The evidence raised concerns that there is a risk that future deaths
will occur in similar circumstances to the Deceased, and in other
circumstances, unless action is taken to review the above issues.

. [request the Greater Manchester Police and the Wrightington Wigan and
Leigh NHS Foundation Trust to consider the above concerns in relation
to Hospitals under the management of the Wrightington Wigan and
Leigh NHS Foundation Trust and I request the Greater Manchester Police
to further consider the concerns in relation to all Hospitals in the Greater
Manchester area.

T also request the Home Secretary and the Secretary of State for Health
to consider the above concerns in relation to all Hospitals in the United
Kingdom.

I request the Home Secretary, the Secretary of State for Health, the
Greater Manchester Police and the Wrightington Wigan and Leigh NHS
Foundation Trust to carry out reviews with regard to the following:-

i. The security of patients under arrest or in the presence of or
supervised by Police Officers in any location within a Hospital.

ii. The protection of other patients in the Hospital, visitors to the

Hospital, members of the public and staff employed in the
Hospital whenever a patient is detained under arrest or in the
presence of or supervised by Police Officers in any location within
a Hospital.

The provision of protocols, policies and procedures as between
Police Forces and Hospital Trusts in relation to the formulation of
joint risk assessments and the inclusion of liaison and
consultation between Police Forces and Hospital Authorities in the
formulation of joint risk assessments in relation to patients
detained at a Hospital under arrest or in the presence of or
supervised by Police Officers.

The purpose of the protocols, policies and procedures would be to
protect the individual patient detained by the Police and to
consider and protect other patients in the Hospital, visitors to the
Hospital, members of the public and staff employed in the
Hospital.

The Home Secretary and the Secretary of State for Health would
be in a position to bring the concerns to the notice of all Police
Forces and Hospitals in the United Kingdom to enable the
concerns to be considered in individual areas or regions as
between individual Police Forces and individual Hospital Trusts on
a nationwide basis. It is accepted that some Police Forces and
Hospital Trusts may already have appropriate protocols, policies
and procedures in place but the evidence at the Inquest was that
they did not exist in many Hospitals in the United Kingdom.

The need for a review both in Greater Manchester and on a
nationwide basis when a patient is detained at a Hospital under
arrest or in the presence of or supervised by Police Officers relates
to the fact that there are special considerations in relation to risk
assessments in relation to such patients that do not arise in
relation to patients who are not detained under arrest or in the
presence of or supervised by Police Officers.

rh

6 | ACTION SHOULD BE TAKEN

In my opinion urgent action should be taken to prevent future deaths and I
believe 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 2nd June 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

L

| is proposed.

COPIES and PUBLICATION

I have sent a copy of my report to the Chief Coroner and to the following
Interested Persons:-

fF Mrs Carney’s daughter.

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 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

9

7™ April 2016 Alan P Walsh HM Area Coroner

Dated Signed

of your response by the Chief Coroner.

Responses

3 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.

Response from Department of Health (PDF)

From Ben Gummer MP
Parliamentary Under Secretary of State for Care Quality

Department Richmond House
of Health 79 Whitehall
peepee en ondon

POC 1028369 RECEIVED SWIA 2NS
6 JUN 2016 Tel: 020 7210 4850

Mr Alan Walsh
HM Area Coroner — Manchester West soer —_
Paderborn House

Howell Croft North
Bolton
BLI 1QY c
( June 2016

Thank you for your letter to Secretary of State about the death of Ms Joyce Camey. I am
responding as the Minister with responsibility for patient safety at the Department of Health.

I was saddened to read of the circumstances surrounding Ms Carney’s death. Please pass my
condolences to her family and loved ones.

Your report outlined the events leading to the injuries sustained by Ms Carney and her
subsequent death.

Although frontline organisations must have a measure of autonomy in operational matters,
your report raises some important points about the way in which the police and hospitals can
work together in these instances. To this end, I have shared your report with NHS Protect,
which is the organisation with responsibility for a wide range of security and protection
issues across the NHS.

NHS Protect would support a joint DH/Home Office initiative to develop protocols, policies
and procedures, to provide a national framework for joint risk assessments between police
and NHS staff for patients detained at a hospital under arrest, or in the presence of, or
supervised by, police officers.

This will enable NHS organisations and police to develop jointly local plans to mitigate
known risks from patients detained at a hospital who may pose a risk to the safety and care of
themselves, other patients, vigitors and staff.

I hope that this informatjon jg useful. Thank you for bringing the circumstances of Ms

Carney’s death to our atte:

Response from Home Office (PDF)

RECEIVED
12 SEP 2016

a Home Sacretary
so 2 Marstiam Street,
Londo) SW1P 4DF

H O m e Offi ce ww. pov.ukshome-office

Alan P Walsh
" Area Coroner
Manchester West

By e-mail —— .
G dune 2016

Doe fhe WSK

CASE OF JOYCE CARNEY

Thank you for your letter of 8 April, covering your report under Regulation 28
regarding the sad circumstances surrounding the death of Joyce Carney.

The arrest, detention and supervision of individuals by police whilst they are patients
in hospital is an operational consideration for the chief officer of each police force. In
carrying out their duties, the police should follow the College of Policing Authorised
Professional Practice’ (APP) - Detention and Custody, which covers risk
assessments when a person is detained in non-police custody settings, including
hospitals. The College have also produced dedicated APP on risk, which focuses on
planning for, and anticipating, risk in a variety of operational-contexts.

It is important that the police adhere to Authorised Professional Prat ctice in these
circumstances to avoid these sorts of tragedies. It is for this reason that | have asked
the Minister for Policing, Fire, Criminal Justice and Victims to write to the National
Policing Lead for Custody, Chief Constable to raise this matter with
Chief Constables across England and Wales. They must be able to satisfy

- themselves that the relevant procedures, including risk assessments, are in place.

Police officers regularly attend health settings, for a variety of purposes, and you
raise the important issue of how they work with NHS organisations to manage any
risks in those settings safely. | agree with you that it is important for those agencies
to come together to make sure that the right relationships and precautions are in
place in their locality. This case highlights the importance of that joint working, and~
the Minister will also be raising this.

You may be interested to know that the College of Policing is leading a programme
. of work aiming. to set a national framework clarifying the roles and responsibilities of

heaith and policing partners to maintain safety in mental health settings. | understand
that a second phase of this work, starting later this yéar, will broaden the
consideration to all health settings. Hopefully this will ensure a consistent approach
to managing risk when the police attend any health setting.

Yosot aa
mp

‘ The Rt Hon Theresa May

Response from Wrightington Wigan and Leigh NHS Trust (PDF)

ReLeIVED

Wrightington, Wigan and Leigh
Myr Andrew Foster

Chief Executive

Wrightington Wigan & Leigh NHS Foundation Trust

Trust Headquarters / The Elms
Wigan WNL INN

2 June 2016 Web: wwwawwhahs.uk

Mr AP Waish

HM Area Coroner
HM Coroner's Office
Paderborn House
Civic Centre

Bolton BLE 1GY

Dear Mr Walsh

Regulation 28 Response: Joyce Carney (Deceased
Thank you for your Regulation 28 Report to Prevent Future Geaths, dated 7 April 2016.

lunderstand that on 23 March 2016 an inquest was held relating te the death of Mrs Joyce Carney. | have been
fully advised of the circumstances relating to Mrs Carney’s death and having read your report, | arn grateful to

you for bringing these concerns to my attention.

Since the conclusion of the inquest Wrightington, Wigan and Leigh NHS Foundation Trust (“the Trust”} has
been working with Greater Manchester Police {GMP} to ensure lessons have been learnt fram the events

surrounding Mrs Carney’s death.

i would now like to take the opportunity to advise you af the actions already taken by the Trust to address the

concerns outlined below and the proposed action to be taken in the near future.
The review has addressed the following:

L. The security of patients under arrest, or in the presence of, or supervised by, Police Officers in any
location within a Hospital.

2. The protection of other patients in the Hospital, visitors to the Hospital, members of the public and
staff employed in the Hospital whenever a patient is detained under arrest, or in the presence of or
supervised by Police Officers in any location within a Hespital.

&
Po $4 fais =
iam *

Chief Executive: Andrew Foster CBE

3. The provision of protocols, solicies and procedures as between Police Forces and Hospital Trusts in
relation te the formulation of loint risk assessments and the inclusion of llsison and consultation
between Police Forces and Hospital Authorities in the formulation of joint risk assessments in
rejation to patients detained at a Nospital under arrest or in the presence of or supervised by Police

Officers.

The following actions have been undertaken in relation to hospitals only under the management of the Trust. 1
is our understanding that GMP will also be working with other Hospital Authorities within the Greater

Manchester area.

Upon receipt of the Regulation 28 Report the concerns raised were discussed at the Trust's Executive Scrutiny
Committee {ESC}. ESC is a weekly meeting, chaired by the Medical Director and Director of Nursing, and all
issues arising from coronial proceedings are discussed within this forum. it was agreed by the Committee that

the review would be led by EEE s:s'scan Director of Nursing & Patient Services (Operatioanall),

| of Nursing for Unscheduled Care}, and a i: 2¢ of Legal Services).
Following the conclusion of Mrs Carney’s inquest IEEE contacted | se inspector}

of GMP and it was agreed that both organisations would work jointly te address the actions outlined at points 1
~3 above. The Trust already has a very good relationship with GMP and this would be utilised to formulate the

required protocols, policies and procedures for the protection of patients, staff and visitors to the hospital.

The first meeting between the Trust and GMP was held on Friday 6 May 2016 by way of telephone conference.
in attendance from the Trust — and from GMP the following persons were present;
(<:e8 ie specto;, ED (chief inspector), EEE (Detective
inspector), BBB P ofessionat Standards Branch), RE} oetective constabtc),
iinspector ~ Custody Branch) and EE 22 Health}. The number of high ranking officers

allocated to this review is testament to how serious both organisations are dealing with this matter.

At the meeting it was agreed that both the Trust and GMP would make enquiries with other organisations
within Greater Manchester to establish if other policies and procedures existed elsewnere to address the
concerns highlighted above. ee 2: already started contacting other Hospital Authorities
to see what ‘good practice’ was in place. However it had soon become apparent that no other NHS Trusts
within Greater Manchester had procedures in place to deal with patients attending hospital in the presence of,
or under police supervision. In light of this it was agreed that the Trust and GMP would have to work together
to formulate a new document in the form of a joint risk assessment that could be used by all police escort staff

and health professionais responsible fer that patient.

The document would need te contain the patient information, the reasons for requiring police escart /
supervision, any known risk factors and brief details of that patient's past criminal background (where
relevant}. The document would also need to contain a risk assessment which would be completed jointly by the
police officer and hospital staff, and this would assess the level of risk that the patient presented to
themselves, staff, or ather members of the public. This would then trigger a Patient Management Plan that
would take into account the location, environment and any other factors relevant te their treatment. Any

change in condition or locality would trigger a joint review of that Plan.

A further meeting was held on Monday 16 May 2036 between ee: GMP.

The purpose of this meeting was to formulate a draft document in readiness for sharing at the next conference

between the Trust and GMP. A working draft was agreed that incorporated all of the factors identified above.

On Friday 20 May 2016 a conference was held at the police headquarters in Manchester. | enclose a copy of
the draft “Patient Under Escort Record” that has been ratified by both organisations. As you will note there are
some minor amendments that are still required, but the overall content has been agreed. Both the Trust and
GMP feel that good progress had been made and the attached docurnent will ensure the security of patients

under police escort, as well as other patients within the hospital, visitors and staff.

The “Patient Under Escort Record” will be completed by the police officer when they attend the hospital site
with the patient. The document will then be completed jointly by GMP and hospital staff throughout the course
af the patient's stay, and will remain with them until discharge. Upon discharge the docurnent will become the
property of GMP who will hold it on file to form part of their intelligence of that patient (should it be required

in the future).

AS | arn sure you will appreciate there are a number of actions that remain outstanding to ensure the “Patient
Under Escort Record” is embedded within both organisations, and to ensure that operationally it is fit for the

purpose intended. The timeline below provides an estimate of the action that will be taken in the near future:

* Final draft of the “Patient Under Escort Record” to be agreed by the Trust and GMP ~ estimated
deadline end of june 2016

* The “Patient Under Escort Record” will be taken to the Trust's Consultant body, Nursing forums,
Safeguarding Leads for discussion ~ estimoted deadline end of fly 2016

® Final version of the “Patient Under Escort Record” to be agreed between the Trust and GMP following
consultation — estimated deadline end of August 2016

* Training on the use of the “Patient Under Escort Record” to be rolled out initially to all staff in A&E and

the assessment areas (MAU and Lowton} - September 2016

* An audit of the “Patient Under Escort Record” will be undertaken after 3 months ~ results to be made

available by December 2016

The above actions will be monitored by the Trust’s Quality and Safety Committee which is chaired a Non-

Executive Director and attended by several members of the Executive tear.

Whilst the above actions are on-going the Trust will continue to work closely with GMP to ensure the security
of all patients brought to the hospital under escort and / or supervision. The welfare and safety of our patients,

staff and visitors to our hospital sites is paramount and something we take extremely seriously.

i hope the above response is testament to how serious both the Trust and GMP have dealt with the events
surrounding Mrs Carney’s death. If you have any comments or suggestions in relation te the proposed actions

above, i would be only too pleased to hear from you.

tunderstand you have also written to the Home Secretary and the Secretary of State for Health to consider the
concerns raised. | would be grateful if you could share their response se that we may seek to take further

action in addition to that outlined above.

Yours sincerely

C&L

Andrew Foster
Chief Executive

The report

Responses

Related reports

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More reports categorised “Hospital Death (Clinical Procedures and medical management) related deaths”

Track Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation Trust