Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0173, written 5 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 | 5 May 2016 |
|---|---|
| Reference | 2016-0173 |
| Deceased | Ahmedreza Fathi |
| Coroner | Lydia Brown |
| Coroner area | Leicester City and South Leicestershire |
| Category | State Custody related deaths · Suicide (from 2015) · Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
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 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Mr lan West. Governor, HMP Gartree. cting Chief Executive. East Midlands Ambulance Service NHS Trust. 1 | CORONER lam Lydia Brown, assistant coroner, for the coroner area of Leicester City and Leicestershire South 2 | 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. 3 | INVESTIGATION and INQUEST On 15 May 2015 | commenced an investigation into the death of Anmedreza Fathi. The Inquest concluded on 12" April 2016. The Juries conclusion was, Suicide on May 13th 2015, Gallow Field Road, Market Harborough, Leicestershire. The circumstances that the deceased came by his death were a combination of plastic bag asphyxia and multi drug toxicity, which we believe to be a deliberate act of suicide. From the evidence presented we are of the opinion that the main two contributing factors to Mr Fathi's actions are; the constant physical pain he was experiencing, and the lack of trust (he developed after acute episodes of anxiety and paranoia) for his support network. With the evidence presented, we have heard that there was a fragmented incohesive approach to the care and support Mr Fathi received which lacked a strategic lead. On the night of 12th May 2015 there were clear changes in Mr Fathi's usual pattern of behaviour that should have been managed more appropriately. It is evident that there was a breakdown in effective communication which led to partial information being provided and inadequate decisions being made. Questions to Jury. Q1) Do you agree the cause of death to be 1a. Combination of plastic bag asphyxia and multi drug toxicity? A) Yes. Q2) Following his admission to Leicester Royal Infirmary on 26th March 2015, was Mr Fathi appropriately risk assessed with access to all relevant information, after his return to HMP Gartree ? A) No. Q3) Did the care plan approach used by the healthcare teams include sufficient detail to ensure all aspects of his safe-keeping were available to and understood by all relevant staff with direct contact with Mr Fathi ? A) No. Q4) Did the prison, primary and secondary healthcare services work together and share appropriate information, and review this regularly, to keep Mr Fathi as safe as can reasonably be expected within a secure prison environment? A) No. Q5) On the evening of 12 May 2015, were the changed observation levels appropriate at all times? A) No. Q6) If your answer to question 5 is "no", do you think that different, more appropriate, observations may have resulted in an alternative outcome on this night? A) Yes. Cause of death 1a Combination of plastic bag asphyxia and multi drug toxicity CIRCUMSTANCES OF THE DEATH Mr Fathi was a serving prisoner on a life sentence at HMP Gartree. He was on an ACCT document for many months and under the ongoing care of the physical and mental health teams, as well as receiving physical health care outside the prison. He had made several attempts to harm himself in the past, including 4 significant episodes during 2015 when he required emergency treatment out of hospital and had threatened to take his own life on many occasions. On 12” May he made a comment to a fellow in-mate that he intended to take his own life that night, and his observation levels were increased, but not to an appropriate level according to the jury's findings of fact. He was discovered in his cell during the night, his head and chest inside a large plastic bag in a collapsed state and resuscitation efforts were unsuccessful. Toxicology revealed high levels of drugs, both prescribed and non-prescribed, that he should not have had in his possession. 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. On previous occasions following deaths in prison locally in Leicester, the Coroner and the PPO have raised concerns regarding delays in requesting 999 emergency assistance. On the night of 12 May 2015 there was a delay in summonsing an ambulance, in breach of PSI 03/13 and the prisons own internal policy. The then serving Head of Safety advised the Court that she “dealt with this problem a lot’. There appeared to be a perception from gatehouse staff that calls had to be delayed until further information could be obtained from those officers at the scene. EMAS advised the court that 3 protocols already exist between other stakeholders and discussions to consider a prison/emergency response protocol would be welcomed and could be accommodated. | therefore encourage both the prison and EMAS to arrange a meeting to take this matter forward. 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 30/06/2016. |, 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. nN COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the following Interested Persons EE (cousin) (PPO) Dr P Miller. Chief Executive, Leicestershire Partnership NHS Trust overnment Legal Dept) Mr J. Adler (Chief Executive University Hospitals Leicester) (Thompsons Solicitors) Ms. Angela Hillery, Chief Executive Northamptonshire Healthcare NHS Foundation Trust | 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 thi e of your response, about the release or the publication of yor nse e Chief Coroner. [SIGNI ER] poral Max ol 5 REGULATION 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Mr lan West. Governor HMP Gartree. Dr P Miller. Chief Executive, Leicestershire Partnership NHS Trust. Ms. Angela Hillery, Chief Executive Northamptonshire Healthcare NHS Foundation Trust. 4 | CORONER lam Lydia Brown, assistant coroner, for the coroner area of Leicester City and Leicestershire South 2 | 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. 3 | INVESTIGATION and INQUEST On 15 May 2015 | commenced an investigation into the death of Anmedreza Fathi. The Inquest concluded on the 12" April 2016. The Juries conclusion was, Suicide on May 13th 2015, Gallow Field Road, Market Harborough, Leicestershire. The circumstances that the deceased came by his death were a combination of plastic bag asphyxia and multi drug toxicity, which we believe to be a deliberate act of suicide. From the evidence presented we are of the opinion that the main two contributing factors to Mr Fathi's actions are; the constant physical pain he was experiencing, and the lack of trust (he developed after acute episodes of anxiety and paranoia) for his support network. With the evidence presented, we have heard that there was a fragmented incohesive approach to the care and support Mr Fathi received which lacked a strategic lead. On the night of 12th May 2015 there were clear changes in Mr Fathi's usual pattern of behaviour that should have been managed more appropriately. It is evident that there was a breakdown in effective communication which led to partial information being provided and inadequate decisions being made. Questions to Jury. Q1) Do you agree the cause of death to be 1a. Combination of plastic bag asphyxia and multi drug toxicity? A) Yes. Q2) Following his admission to Leicester Royal Infirmary on 26th March 2015, was Mr Fathi appropriately risk assessed with access to all relevant information, after his return to HMP Gartree ? A) No. Q3) Did the care plan approach used by the healthcare teams include sufficient detail to ensure all aspects of his safe-keeping were available to and understood by all relevant staff with direct contact with Mr Fathi ? A) No. Q4) Did the prison, primary and secondary healthcare services work together and share appropriate information, and review this regularly, to keep Mr Fathi as safe as can reasonably be expected within a secure prison environment? A) No. Q5) On the evening of 12 May 2015, were the changed observation levels appropriate at all times? A) No. Q6) If your answer to question 5 is "no", do you think that different, more appropriate, observations may have resulted in an alternative outcome on this night? A) Yes. Cause of death 1a Combination of plastic bag asphyxia and multi drug toxicity 4 CIRCUMSTANCES OF THE DEATH Mr Fathi was a serving prisoner on a life sentence at HMP Gartree. He was on an ACCT document for many months and under the ongoing care of the physical and mental health teams, as well as receiving physical health care outside the prison. He had made several attempts to harm himself in the past, including 4 significant episodes during 2015 when he required emergency treatment out of hospital and had threatened to take his own life on many occasions. On 12" May he made a comment to a fellow in-mate that he intended to take his own life that night, and his observation levels were increased, but not to an appropriate level according to the jury's findings of fact. He was discovered in his cell during the night, his head and chest inside a large plastic bag in a collapsed state and resuscitation efforts were unsuccessful. Toxicology revealed high levels of drugs, both prescribed and non-prescribed, that he should not have in his possession. 5 | COR R'S C ERN. 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. Healthcare complex case planning was not robust or effective, and was not reviewed or updated in response to subsequent events. Multi-disciplinary team meetings, if they took place, were not formalised and there was no ready access to all relevant information relating to risk assessment and case management through either System1 (the medical record storage and case management system) held by healthcare, or the ACCT document held by the prison. 2. The enhanced case management system referred to in PSI 64/11 was under- utilised for a prisoner of this complexity and further consideration should be given to its role in situations of this nature. 3. Mr Fathi was taken to hospital with (on the balance of probabilities) an earlier overdose, some weeks before he lost his life. Neither the prison services nor healthcare considered the significance of this event, raised any hospital enquiries or completed an accident/near-miss incident report procedure and applied learning outcomes. This was a missed opportunity to consider Mr Fathi's intentions, his ability to access drugs in appropriately and to take appropriate safeguarding actions. Consideration should be given to adopting a system that ensures investigating such events on each occasion to ensure lessons can be learnt. 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. Nu | YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report. namely by 30/06/2016.1, 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 3 | COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the following Interested Persons. Cousin) (PPO) ‘Government Legal Dept) Mr J. Adler (Chief Executive UHL) Me ces Solicitors) a Acting Chief Executive. (EMAS) | 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/pf ypwr response by the Chief Coroner I er PPS ley a6 SPT
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.
~~GR~~~~~ _, %,$r~ East Midlands Ambulance Service '' "~ Emergency Care ~ Urgent Care (1Ne Care Trust Headquarters 1 Horizon Place Mellors Way Nottingham Business Park Nottingham NG8 6PY Telephone: 0115 884 5000 Fax: 0115 884 5001 Website: www.emas.nhs.uk Our ref: 25 July 2016 Mrs Lydia Brown HM Assistant Coroner. Leicester City and Leicestershire South The Coroner's Court Town Hall Town Hall Square Leicester LE1 9BG I~Z~Tii11 • . ~ Re: Report to Prevent Future Deaths: Ahmedreza Fathi (DECEASED) Thank you for your Regulation 28 Report to Prevent Future Deaths, dated 11 May 2016, bringing to my attention HM Coroner's concerns arising from the Inquest into the death of Ahmedreza Fathi. I would like to re-emphasise our apologies for the failure to respond to the original Regulation 28 Report. An initial investigation has not found evidence of receipt of this report, however our management of Coronial processes is under review to ensure stronger and more robust handling of all cases to avoid such events in the future. would like to reassure you that within the East Midlands Ambulance Service (EMAS) all matters related to patient safety are taken extremely seriously. In particular, any matters arising from Coroner's Inquests from which lessons can be learnt, and this includes any Prevention of Future Deaths notices, are discussed within the Coroners Working Group. The Coroners Working Group, having considered all the relevant issues of concern relating to the particular Inquest at hand, will then develop an appropriate action plan with specified timelines for each action, together with identified individuals to deliver the actions specified. This process has been applied to the Prevention of Future Deaths notice (PFD notice) pertaining to the Inquest into the death of Ahmedreza Fathi. d~, _- 4a, ~ ~ Y. =~ ~~, ~;_:- ~~::~'~ East Midlands Ambulance Service ~ ~` r ~lHs Trust Emergency Care ~ Urgent Care (1Ne Care The MATTERS OF CONCERN are as follows: • On previous occasions following deaths in prison locally in Leicester, the Coroner and the PPO have raised concerns regarding delays in requesting 999 emergency assistance. On the night of 12 May 2015 there was a delay in summonsing an ambulance, in breach of PSI 03/13 and the prisons own internal policy. The then serving Head of Safety advised the Court that she "dealt with this problem a lot". There appeared to be a perception from gatehouse staff that calls had to be delayed until further information could be obtained from those officers at the scene. • EMAS advised the court that 3 protocols already exist between other stakeholders and discussions to consider aprison/emergency response protocol would be welcomed and could be accommodated. I therefore encourage both the prison and EMAS to arrange a meeting to take this matter forward. set out below the actions EMAS has taken and our response to HM Coroner's concerns as detailed in the PFD notice. To address the specific issues identified in relation to Gartree Prison, alongside informing wider regional secure units, an initial meeting has been scheduled for Wednesday 3 August 2016. This meeting will be attended by the (Consultant Paramedic Lead) from EMAS, and the Head of Operations .and Senior Operations Team from HMP Gartree. This meeting will aim to set an agenda to address access issues, ambulance activation protocols and partnership working principles. It is planned that this will be the first of a number of meetings and workshops to address the identified issues and available opportunities. (Deputy Medical Director), EMAS has been proactively working with secure environment teams to develop working practices to create safe and efficient care delivery. This has been led by local management teams based upon locally identified needs. A key example of this working is the provision of SEND cards (Secondary Emergency Notification of Dispatch) for all secure environments for staff issue. These cards identify the core information required by the AMPDS triage system to appropriately triage patients and act as an aide memoire for front line police and public safety officials. I n order to provide suitable oversight, leadership and empowerment to change, EMAS has now formed a senior regional group to address issues relating to secure environments such as prisons and secure mental health units etc. This centralised approach will enable a consistent and informed approach to this complex area of healthcare provision. This group has membership of senior team members from the Operations Directorate, Medical Directorate, Emergency Planning and Resilience Directorate and Emergency Operations Centre. „V iil ~4~a~~~ ~.z~,~~ `~'-~:'~~~ East Midlands Ambulance Service ~~ .'m tVNs Trust Emergency Care ~ Urgent Care (We Care hope that you agree that EMAS have taken initial steps to ensure that the provision of high q uality emergency care for secure environments working alongside partner agencies. I can assure you that we are taking the actions identified with a view to ensuring that similar tragic events can be avoided wherever possible in the future and that lessons are learnt. Please do not hesitate to contact me should you require any additional information, or any clarification, in connection with the above. Yours sincerely ~~~~~ Interim Chief Executive
~~· National Offender Management Service Equality, Rights and Decency Group National Offender Management Service ◄ th Floor. Chve House. 70 Petty France. London. SW1H 9HD Lydia Brown Assistant Coroner for Leicester City and Leicestershire South 24 June 2016 Dear Ms Brown Regulation 28 Report following the inquest into the death of Mr Ahmedreza Fathi on 13 May 2015 at HMP Gartree Thank you for your Regulation 28 report of 5 May addressed to the Governor of HMP Gartree and the East Midlands Ambulance Service NHS Trust, concerning the recent inquest into the death of Mr Ahmedreza Fathi. Your report has been passed to Equality, Rights and Decency (ERD) Group in NOMS, as we are responsible for sharing learning from deaths in custody. This response has been prepared in consultation with the Governor of HMP Gartree. In your report you repeat the concern that you, the Coroner and the PPO have raised following previous deaths in prisons in the Leicester area about delays by prison staff in calling for an ambulance. You point out that the East Midlands Ambulance Service NHS Trust (EMAS) had advised the court that discussion of a prison emergency response protocol would be welcomed and encourage the prison and EMAS to arrange a meeting to take this forward. You will be aware that PSI 03/2013 Medical Emergency Response Codes sets out the national instruction for calling a medical emergency over the establishment radio network in all prisons and NOMS-operated Immigration Removal Centres HMP Gartree has revised the local contingency plans and re-issued instructions in May 2016 to ensure that all staff understand that they must not delay calling an ambulance in all cases where there are serious concerns about the health of an offender. The local protocols now provide clear guidance to all staff to ensure timely, appropriate and effective responses to medical emergencies In addition HMP Gartree and other prisons in the Leicester area are collaborating with the EMAS to ensure effective Joint working and consistency of approach in all the prisons. Representatives of the prison met with EMAS in April 2016, and there is an expectation that a joint emergency response protocol will be in place by 31 July 2016 Thank you for bringing these matters of concern to our attention. I hope that this letter has been helpful in providing some national context and in giving you assurance that the concerns that you have raised have been, or are being, addressed locally at HMP Gartree and in the other prisons in the Leicester area. Yours sincerely NOMS Equality, Rights and Decency Group
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