Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0148, written 15 Apr 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 Apr 2016 |
|---|---|
| Reference | 2016-0148 |
| Deceased | Luke Ayres |
| Coroner | Emma Brown |
| Coroner area | Birmingham and Solihull |
| Category | Suicide (from 2015) · Mental Health related deaths · State Custody related deaths |
| Organisation named | Birmingham and Solihull Mental Health NHS Foundation 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.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Birmingham and Solihull Mental Health NHS Foundation Trust CORONER | am Emma Brown Area Coroner for Birmingham and Solihull 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 08/10/2015 | commenced an investigation into the death of Luke Christie AYRES. The investigation concluded at the end of the inquest . The conclusion of the inquest was: “Luke was found unresponsive in his room around 7pm on 27 September 2015 with a ligature around his neck. Resuscitation was attempted but Luke could not be resuscitated.” The medical cause of Luke’s death was: 1(a) SUSPENSION BY A LIGATURE AROUND THE NECK CIRCUMSTANCES OF THE DEATH Luke was 24 years old when he died on the 27" September 2015 at the time of his death he was serving a custodial sentence as an inpatient at Raeside Clinic under section 45(a) of the Mental Health Act. Luke was on the intensive care ward, ward Severn, on the 27" September 2015. At approaching about 18.55 a HCA noticed that Luke had covered his observation window in his bedroom door, this sparked a series of events that Jed to his door having to be opened with the anti-barricade system at about 19:00 when Luke was found hanging by a ligature made of a piece of cord placed over the top of the bedroom door. CPR was commenced and an ambulance crew arrived at Luke’s side at about 19.09 but Luke could not be resuscitated. The case gave rise to issues surrounding the risk assessment of Luke, the operation of the anti-barricade system and the actions of staff from the point when they realised they couldn’t get into Luke’s room onwards. 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 999 calf to the ambulance service made by Raeside reception after the issuing of a 2222 medical emergency call was cut off when they attempted to transfer the Ambulance Service to Ward Severn, The Ambulance Service therefore had to get the number from the operator and called back a minute later. When they were put through to the Ward the person they were speaking with was not at Luke’s side and did not know his current status because she was in an office some distance away from him and the staff with him. There is no evidence that this actually had an impact on Luke’s death but there are risks for the future arising from the fact that: - . a) the Ward staff do not call 999 themselves necessitating a delay and a risk of the call being cut off when the call is transferred to the Ward; and b) the person providing information to the Ambulance Service may not know the patient's current status and could therefore give incorrect information. 2. The evidence was that when the Paramedics arrived in reception no-one was present to escort them to the Ward and only once they had arrived did a member of staff go to meet them. This is a source of obvious and dangerous delay. 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 15 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 is proposed. COPIES and PUBLICATION ! have sent a copy of my report to the Chief Coroner and to the following Interested Persons: the parents of Luke Ayres and their legal representatives. |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. 15/04/2016 Signature Emma Brown ‘Coroner Birmingham and Solihull
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.
©) Birmingham and Solihull ~ Mental Health NHS Foundation Trust Chair & Chief Executive’s Office Unit 1, B1 50 Summer Hill Road Ladywood Birmingham B1 3RB Tel: 0121 301 1319 Fax: 0121 301 1301 Mrs Emma Brown HM Coroner, Coroners Court Birmingham and Solihull Areas 50 Newton Street Birmingham B4 6NE 1 June 2016 [ RECEIV ED | Dear Mrs Brown, | REGULATION 28: REPORT TO PREVENT FUTURE DEATHS | write in response to the Prevention of Future Deaths report that was issued following the inquest into the death of Luke Ayres with assurance of the action that we are taking in relation to your concerns. Luke Ayres sadly died when he was an inpatient on Severn Ward, Reaside Clinic on 27 September 2015. Luke was found kneeling on the floor with a ligature around his neck at approximately 7pm that evening and despite attempts by staff and paramedics, he was unable to be resuscitated. There are a range of improvement measures that we have put in place as a result of the death of Luke as part of our serious incident investigation. These include:- e Implementation of a single anti barricade system on Severn Ward e Funding allocation to enable the whole of Reaside Clinic to operate a single anti barricade system ‘the Kingsway system’. Works have already commenced in this regard and will complete at the end of September 2016. The Kingsway system will also be operating on Severn Ward at this stage e Replacement of 70 observation panels at Reaside Clinic e Piloting of a new clinical handover tool — the WHAT tool on Severn Ward. Initial evaluation has proved positive and we are now seeking to roll out this approach to documented longitudinal and cross sectional risk within clinical handover across the Trust e A review of our observation policy - amendments to the policy and associated training requirements are scheduled to be approved in July 2016 e Implementation of a more robust approach to Environmental and ligature risk assessments with input from subject matter experts from the Health and Safety Team, Estates and Facilities Team working alongside Ward Managers Chair: Sue Davis, CBE Chief Executive: John Short Customer Relations Mon - Fri, 8am —- 8pm Tel: 0800 953 0045 Text: 07985 883 509 Email: customerrelations@bsmhft.nhs.uk Website: www.bsmhft.nhs.uk Mey. Stonewall 3 O04 . VV DIVERSITY Impreving mental health wellbeing spar During the inquest, evidence gave rise to concern about the procedures associated with the handling of medical emergency calls at Reaside Clinic, together with a lack of assurance that Paramedics would always be greeted in reception by a member of ward staff who could immediately escort them to the scene of the incident. As a result of these concerns we have reviewed all of the technical telephony reports associated with the medical emergency call and can see that the call to the ambulance service was cut off during or immediately following transfer from reception to Severn Ward. We believe that this was user error on this occasion, however we are aware that the telephony system at Reaside Clinic is very aged and cannot therefore rule out a technical fault. We have therefore approved funding to replace the telephony system at the clinic so that it is in line with systems in place across our other Trust sites. We anticipate that this work will commence in Quarter 3 of this year (circa October 2016). We would like to thank you for bringing this matter to our attention. During the inquest you raised concern that the individual handling the medical emergency call was not at the side of the patient and questioned whether it would be appropriate to therefore have a cordless telephone on the ward for use in medical emergency situations. We have explored this matter with our information technology colleagues. Sadly due to the age and construct of the building at Reaside Clinic, there are a range of points where wi-fi connection cannot be assured. We therefore believe that a cordless telephone may result in greater risk of delay in gaining medical emergency response. We have therefore decided to extend the simulation of medical emergencies on our wards at Reaside to include the connection of the call to the ambulance service and to also ensure that the individual nominated to make the call has all of the relevant medical information and observations of the patient to hand. We currently deliver quarterly medical emergency simulation exercises at Reaside Clinic (the most recent being just 2 weeks ago) and will explore the possibility of increasing the frequency. On the matter of receiving the Paramedics at the Clinic, we have amended our local protocol to ensure that the nurse in charge nominates an individual to await arrival of the Paramedics. This individual will also wear a high visibility vest so that they are immediately identifiable upon arrival of the paramedic team. We believe that the improvements identified above will enhance our current arrangements for medical emergencies at Reaside Clinic and would like to thank you once again for bringing these matters to our attention. You may find it helpful if | write to you again in six months to update you on our progress and | will diarise this accordingly. Yours sincerely Pprrsnort John Short Chief Executive
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