Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0205, written 31 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 | 31 May 2016 |
|---|---|
| Reference | 2016-0205 |
| Deceased | Danielle Robinson |
| Coroner | John Gittins |
| Coroner area | North Wales (East and Central) |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths · Suicide (from 2015) |
| 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 (1) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: BCUHB, Ysbyty Gwynedd, Penrhosgarnedd, Bangor, Gwynedd LL57 2PW 1 | CORONER ! am John Gittins Senior Coroner, for the coroner area of North Wales (East and Central)] 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 20" November 2014 | commenced an investigation into the death of Danielle Rhian Robinson aged 21. The investigation concluded at the end of the Inquest held with a jury on the 25" of May 2016. The conclusion of the Inquest was that Miss Robinson’s death was the result of Misadventure. The medical cause of death was l(a) Post Cardiac Arrest Hypoxic Brain Injury with Cerebral Oedema due to 1(b) Ligature Strangulation 4 | CIRCUMSTANCES OF THE DEATH (1) Miss Robinson was a 21 year old who was detained under s.3 of the Mental Health Act at the Heddfan Unit of Wrexham Maelor Hospital. During the time she was a patient at Heddfan she had repeatedly self harmed, primarily by the placing of ligatures around her neck. (2 SS On the 13" of November 2014 she was found unresponsive in her room with a ligature around her neck. At this time, despite earlier episodes of both self harm and absconding from the unit she was on level 1 observations (being every three hours). Despite resuscitation attempts and subsequent treatment she died on the 16! of November 2014. 5 | 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) That the Therapeutic Engagement and Observation Policy presently adopted by BCUHB is not being rigorously followed by staff with the result that opportunities to escalate the level of observations when required are being missed. (2) That the current Therapeutic Engagement and Observation Policy there should be reviewed with consideration being given to implementing a system for situations where there is a serious event which places a patient at risk of immediate or imminent harm, that there should be an automatic escalation of observation levels to level 3 or 4 (within eyesight or arm’s length respectively) for a designated period and/or one to one engagement with the patient so as to provide an instant “safety net”. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe your organisations 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 27 July 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 Person: ATC rents of the Deceased) | 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. [DATE] 315 May 2016 SIGNED BY SENIOR CORONER] CAKE
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.
Heddfan AMHU, Ysbyty Maelor Wrecsam, Wrecsam, LL13 7TD ---------------------------------- Heddfan AMHU, Wrexham Maelor Hospital, Wrexham, LL13 7TD Ein cyf / Our ref: Eich cyf / Your ref: Ffôn / Telephone: Gofynnwch am / Ask for: E-bost / Email: Dyddiad / Date: 27 July 2016 Mr J A Gittins H M Coroner Coroner’s Office County Hall Wynnstay Road Ruthin LL15 1YN Dear Mr Gittins In response to the Regulation 28, issued on May 28th 2016 as a result of the inquest into the death of Miss Danielle Rhian Robinson. I can confirm that the BCUHB Therapeutic Engagement and Observation Policy has been reviewed and updated to include the automatic escalation of observations following serious attempt of self-harm until a full multi-disciplinary team (MDT) review can take place, a copy is enclosed for your information. Roles and responsibilities of all staff are clearly detailed within the policy. In relation to the ongoing monitoring of compliance, an audit process is included which will now form part of the divisional audit cycle with outcomes and suggestions for improvements formally reported through our divisional governance structure to QSE. The division has its first learning event planned for September 2016 and the policy will be formally re-launched at this event. Yours sincerely Cyfarwyddwr Iechyd Meddwl ag Anabledd Dysgu Director of Mental Health and Learning Disabilities Cyfeiriad Gohebiaeth ar gyfer y Cadeirydd a'r Prif Weithredwr / Correspondence address for Chairman and Chief Executive: Swyddfa'r Gweithredwyr / Executives’ Office, Ysbyty Gwynedd, Penrhosgarnedd Bangor, Gwynedd LL57 2PW Gwefan: www.pbc.cymru.nhs.uk / Web: www.bcu.wales.nhs.uk
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