Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0169, written 3 May 2016. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 3 May 2016 |
|---|---|
| Reference | 2016-0169 |
| Deceased | Mihangel ap Dafydd |
| Coroner | Jonathan Layton |
| Coroner area | Carmarthenshire and Pembrokeshire |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths · Mental Health related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Chief Executive West Wales General Hospital Glangwili Carmarthen Carmarthenshire SA31 2AF CORONER 1 I am Jonathan Mark Layton, senior coroner for the coroner area of Carmarthenshire and Pembrokeshire. 2 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. 3 INVESTIGATION and INQUEST On 18th February 2014 I commenced an investigation into the death of Mihangel ap Dafydd. The investigation concluded at the end of the inquest on 29 April 2016. The conclusion reached by the jury was a narrative one namely that: On 16th February 2014 Mihangel ap Dafydd hanged himself on Morlais Ward Glangwili Hospital. He was properly assessed under the Mental Health Act upon his admission to hospital. His level of observation was appropriate in the circumstances. The procedure for removing items of property which could be used for the purposes of self-harm was undertaken incorrectly. The hospital unit had not been correctly adapted to prevent windows being used as a ligature point. These failings did contribute to his death. 4 CIRCUMSTANCES OF THE DEATH (1) On 14th February 2014 Mr ap Dafydd was exhibiting signs of mental illness and was assessed as being at risk of self-harm. (2) He was detained under the Mental Health Act and placed under 15 minute observations on Morlais Ward Glangwili Hospital. (3) He was checked during the early hours of 16th February and was found hanging from a window having used a strap from his bag. 5 CORONER’S CONCERNS During the course of the inquest the evidence revealed this matter 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 is as follows: The windows in service user areas at Morlais Ward are not ligature free and whilst it is intended to make them so following the death of Mr ap Dafydd this work has not yet been undertaken. 1 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you 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 the 28th 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. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Person: Welsh Government Cathays Park Cardiff CF10 3NQ 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 of your response by the Chief Coroner. 9 3 May 2016 Signed: 2
2 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.
Bwrdd lechyd Prifysgol Hywel Dda University Health Board flOur ref: Private & Confidential Mark Layton Coroner for the Districts of Carmarthenshire and Pembrokeshire Coroner’s Office Town Hall Hamilton Terrace Milford Haven Pembs SA73 3JW Dear Mr. Layton Re: Inquest into the death of Mihangel ap Dafydd Thank you for your letter dated the 29th April, and the Regulation 28 report for the Health Board's attention. I can confirm that the Health Board undertakes an annual point of ligature audit programme across all of its mental health and learning disability in- patient units, which includes an audit of Morlais Ward on the West Wales General Hospital site. The point of ligature audits undertaken following Mr. ap Dafydd's death identified potential point of ligature risks with windows on a number of the in-patient units, including Morlais Ward which were reported through the Heaith Board's Capital programme. The point of ligature programme is considered alongside all of the annual priorities across the Health Board, and the replacement of windows was not deemed to be the greatest priority, as following identification of the risk, steps were taken to mitigate the risk, including the securing of windows in some areas. The point of ligature audit programme plans to repeat the audit of all inpatient units across mental health and learning disabilities in May/June 2016. Following which a prioritised recommendations will be submitted for consideration by the 2016/17 Capital programme, for each unit considering Swyddfeydd Corfforaetho!, Adeilad Ystwyth, Corporate Offices, Ystwyth Building, Cadeirydd / Chair Hafan Derwen, Parc Dewi Sant. Heo! Ffynnon Job, Hafan Derwen, St Davids Park, Job's Well Road, Mrs Bernardine Rees OBE Caertyrddin, Sir Gaerfyrddin, SA31 BB Carmarthen, Carmarthenshire, SA31 3BB Prif Weithredwe/Chief Executive Mr Steve Moore replacement, repair or adaptation of the existing windows in line with the Department of Health Building Note 03-01. Whilst the programme of work is being developed and prioritised it is essential that the inpatient units that require adaptations to windows are able to provide a safe and therapeutic environment for patients. Ensuring patient dignity and safety are priority for the Mental Health and Learning Disabilities Directorate. During the programme of work that will be undertaken, inpatient areas will continue to be subject to regular environmental risk assessment. Where necessary, actions will be taken to mitigate risks that take into consideration patient dignity and comfort. Yours sincerely SeMooe Steve Moore Chief Executive
Val Whiting Dirprwy Gyfarwyddwr, Cyfalaf, Ystadau a Cyfleusterau/ Deputy Director, Capital, Estates & Facilities Mark Layton H M Senior Coroner for the Areas of Carmarthenshire & Pembrokeshire Coroner’s Office Town Hall Hamilton Terrace Milford Haven Pembrokeshire SA73 3JW 3 June 2016 Dear Mr Layton, Acting Chief Medical Thank you for your email of 3 May to Officer, enclosing your Regulation 28 report following the death of Mihangel ap Dafydd at Morlais Ward, West Wales General Hospital, Glangwilli. I am replying in my role as the lead official for NHS estates and facilities issues within Welsh Government. I note your report and requested actions have been sent to the Chief Executive of Hywel Dda University Health Board. However, given that you have identified issues which are of relevance to all NHS organisations, I can confirm that we will be issuing an addendum to Health Building Note 35 – “Accommodation for People with Mental Illness Part 1: The Acute Unit the Ligature Free Design”. This addendum will specifically highlight requirement for ligature free design in both new and existing acute mental health unit facilities in Wales. The addendum to the Health Building Note will also widen the requirements to other facilities dealing with acute mental health in-patients including Children & Adolescent Mental Health Services (CAMHS). This document is in the process of being finalised by Welsh Government officials and our NHS estates advisors and will issue by the end of this month. In addition to the above, I have also requested that NHS Shared Services Partnership – Specialist Estate Services (NWSSP-SES) undertake a formal review of HBN 35. This will consider if the HBN needs more substantial amendment or if it should be superseded by a revised HBN 03-01, amended, where required, to reflect further developments in Welsh Government policy and any specific needs of NHS Wales. I will pick up the individual circumstances and actions taken by Hywel Dda University Health Board at Glangwili Hospital when I next meet the Health Board later this month. I hope you find this information useful. Please do not hesitate to contact me if you have further concerns or queries. Yours sincerely Val Whiting cc: , Deputy Director for Mental Health & Vulnerable Groups Policy Acting Chief Medical Officer Director NHS Wales Specialist Estates Services 2
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