Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0223, written 13 Jun 2016. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 13 Jun 2016 |
|---|---|
| Reference | 2016-0223 |
| Deceased | Laura McRory |
| Coroner | Nadia Persaud |
| Coroner area | East London |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| 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 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. John Brouder, Chief Executive, North East London Foundation Trust, Goodmayes Hospital, Barley Lane, Goodmayes, Ilford, Essex, IG3 8XJ 1 | CORONER | am Nadia Persaud, Senior Coroner for the Eastern Area of Greater London 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. http://www. legislation.gov.uk/uksi/2013/1629/part/7/made 3 | INVESTIGATION and INQUEST On the 24" June 2015 | commenced an investigation into the death of Laura Theresa McRory. The investigation concluded at the end of the inquest on the 6" June 2016. The conclusion of the inquest was a narrative conclusion: Mrs Laura McRory suffered from severe anxiety and associated alcohol misuse. She was noted to be deteriorating in her mental state and alcohol misuse in the weeks leading up to her death. On 20" June 2015 she was taken to hospital by her sister in the hope of receiving help. After assessment by a registered mental nurse, she was discharged home, without any immediate follow up or continued observation. The following day her husband found her intoxicated and later unresponsive. She died from alcohol and mixed drug consumption. The evidence does not reveal her intention at the time of. consuming the fatal mix of drugs and alcohol. 4 | CIRCUMSTANCES OF THE DEATH Laura McRory was a 40 year old lady who had a past medical history of recurrent episodes of anxiety and depression, associated with alcohol misuse. She worked for the North East London Foundation Trust (NELFT). In the weeks leading up to her death, she suffered a deterioration in her mental state and increase in alcohol consumption. She was taken to Whipps Cross Hospital A&E on the 20" June 2015. She was assessed by the NELFT psychiatric liaison team (a Registered Mental Nurse). Mrs McRory made it clear that she did not want to be assessed by staff working for the same Trust as her. The RMN in his statement to the Court stated: “A voluntary psychiatric admission was not the direction Mrs McRory wanted to go, not least because it would have meant further assessment by the Home Treatment Team for consideration; the very same service that she worked in, which would have been utterly humiliating” Mrs McRory was discharged from hospital, following the psychiatric team’s assessment. The following day Mrs McRory was found by her husband to be unresponsive. Paramedics were called, but she could not be resuscitated. Post mortem investigations revealed a cause of death of alcohol and mixed drug consumption. | heard evidence during the course of the inquest fro ME He confirmed his opinion that a more robust safety plan should have been in place at the end of the psychiatric consultation on the 20" June 2015. In particular, he considered that there should have been a request for Mrs McRory to be admitted under the medical team for observation. An admission under the medical team may well have been acceptable to Mrs McRory as this was not the Trust for whom she worked. It was clear from the evidence of her sister that the A&E staff had considered that Ms McRory required admission. also considered that a protocol was required, to deal with the issue of referral out to a neighbouring Trust, where a member of NELFT staff requires mental health care. 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. — e Mrs McRory was employed by the North East London Foundation Trust. She was clearly concerned about providing thorough and detailed information to NELFT staff, concerning her mental state and alcohol misuse. e The evidence revealed a need for a clear process to be in place when NELFT staff require mental health care and express reservations about sharing information with colleagues. e The Trust's investigation report found that there were no care or service delivery problems. The report however did not analyse to any degree the issues relating to the complexities surrounding NELFT employees seeking help for mental health conditions. The report also did not to any extent consider whether there was an adequate safety plan in place on discharge. ¢ [HE cic not consider there to be an adequate safety plan in place for Mrs McRory. He also considered that there needed to be a system in place for staff to be promptly referred to a different Trust where they present with mental health difficulties and request services from a different Trust. ENGid confirm that he was in the process of drafting a protocol to deal with this issue. A copy of the draft protocol was not provided. e In light of the length of time that has elapsed since the date of Mrs McRory’s death and the inadequacies of the Trust’s internal investigation, | consider it necessary to write a Regulation 28 Report to ensure that the Trust considers the system in place for prompt referrals to be made to another Trust, where necessary, for members of NELFT staff who require mental health care. If a protocol is to be drafted, | would like the Trust to confirm how this will be disseminated to frontline staff. 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 8" August 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. COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the following interested persons: BS (4.sb2nc), EE (Mother) ancl (Sister). | am also forwarding a copy of the report to the Care Quality Commission and to , Director of Public Health — who may find it useful or of interest. | am also under a duty to send the Chief Coroner a copy of your response. | will also disclose your response to the above, interested persons. 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] [3-6 (lo [SIGNED BY CORONER] icne=
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.
NeLet WG Best care by the best people NHS Foundation Trust Sent by email to: Nadia.Persaud@walthamforest.gov.uk PRIVATE & CONFIDENTIAL Trust Head Office Ms Nadia Persaud Goodmayes Hospital Senior Coroner Barley Lane Walthamstow Coroners Court Ilford Queens Road 1G3 8XJ Walthamstow London E17 8QP Tel: 0300 555 1298 3rd August 2016 Dear Mss Persaud, Re: Regulation 28 report following the inquest touching the death of Mrs Laura McRory | refer to your Regulation 28 report dated 13th June 2016. The Trust has carefully considered your report and is fully cognisant of the issues you have raised. The Trust is committed to continuously review its service for the purposes of improving quality of care and patient safety and | am grateful for bringing these issues to my attention. Please find enclosed the Trust’s action plan to prevent the reoccurrence of the shortcomings identified in your Regulation 28 report. Yours sincerely, oar com Chief Executive www.nelft.nhs.uk at A VE CL SS me ss Oy Me ren 3 YOYs . 2 Chair: as " S sar Chief Executive: “PRV SSOID SddiyM U! SadIAJaS |ed|PawW "73 pue d1y3e1YyoAsd uasamjaq asnsiw adueysqns WO} BB1eYISIP UO YIIAN7 *y9e4} UO ajep UO!}aj]dWo} pue uolje!xojU! |oYyorje J0y JUaWAaSeueWW 40} aoe;d ul uejd Ajajes *ssan0id ul UOIPY 9TOZ 4890390 ,.TE YI 10} JOIOJ Od Jea]d e Ysij|qezsa OL ajenbapeul ue sem ajay “Bulused| << Ajnuap! pue ssad0id au} ssnosip 0} SuljaawW *yoeJ] UO a}ep UO!}a|dWwoD . . sq payeen Sinaayy 9T0Z MAIADI AIIIA|JI1 & BYLUAPUN 0} JO UBIS |S asaeyosip 91/80/vz 404 * Jaquiaidas ,,0€ | U! parjoau! asou} pue saBeuew Wea} ‘ssoyne |S uo aoejd ui ueyd Ajajes ayenbape ue sem asay} 494}@yM pue suo!puod PAP RT TERY STACI D] SPE PAay SIBLE “pasies SUJ9U09 BY} ssNdsip 0} | YyyYeay jeyUaW 104 Aoddns 34 Buljeaw IS 34 Buneaw IS eee pajajdwoz aoejd uae} sey Suljaaw e - ssauaieme Wea} |S Suyaes yyeys 14743N y a ie Sulpunouuns saiqixejdwioo “s]UaWIWOD JO} JNO AjjUa.Nd 3Y} 0} Zulzejai Sanssi 3pd°Anijod Is . aug 0} sjuawpuawy SISIUL “YOL 8UIQAS pUe JJO BUIUBIS BSOY} JO aj01 | 94} aau3ap Aue 0} asAjeue = Q9TOZ Jequiaydas OF dy} UaYBUa}s 0} payepdn uaagq sey 3SI| Y9aYyd }OU pip quaproU! Siu? a pue Aaijod |s au} — sodas |§ ay} JO HO BulUsIs | OU! UOeSIYSAAU! YsNIL SYL *yoeJ} UO ajep UO!}aj]dWOD “ssaooid ul uo “aWWUeIBOId 54 djay ureygo 01 syers ssau| eM s,LITIN BIA pue Jauedju! 4ye}s UO “LATAN 404 jo20301g 9T0Z 4890290 ,.TE uoljeo1|qnd ‘apedsed elA [090301 ay} Jo a1eMe = apew aq 0} LATIN UlyUM jeIs pue ssaSeueW| = [a] eased yyyeay jequaw “HeIS YUM UO!}e}NSUOD “Adl|Od YH LATIN U! pappaquia aainbas oym ers 1474N dapun Ajjuaiino s! pue padojanap 9T0Z pue padojanap aq 0} aed yyeay jeyUaW 40} a2e;d ul aq 0} ssaz0id uaaq sey jov0}01d yep 7 Jaquiaydas ,,0€ Inbas jyeys 10 ssadoid By} UO [oD0}01d ¥ | 4ea]D e AOJ paau e SI a1aYyL aouapina/ssas1d01d peoq awesjouly uaye} aq 0} UOIDY usaau0) 9toz ann (911) SHLV4G 3YN.LNA LNFAINd OL LYOdaY 8Z NOILVINDIY OL NOILW13Y NI NW1d NOILLOV ysn4j UOIZePUNOY SHN SHN Bee. ajdoad jseq aui Aq sie> jsag
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