Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0306, written 15 Aug 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 Aug 2016 |
|---|---|
| Reference | 2016-0306 |
| Deceased | Oliver Ford |
| Coroner | Maria Voisin |
| Coroner area | Avon |
| Category | Mental Health related deaths |
| Organisation named | Avon and Wiltshire Mental Health Partnership NHS 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 (1)
NOTE: This form is to be used after an inquest.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
41. Dr. H. Richards
Chief Executive
Avon & Wiltshire NHS Partnership NHS Trust
Jenner House
Langley Park Estate
Chippenham
SN15 1GG
1 | CORONER
| am Maria Voisin, Senior Coroner, for the Area of Avon
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 24" August 2015 | commenced an investigation into the death of Oliver Hamlin
FORD, Aged 25. The investigation concluded at the end of the inquest on 10" August
2016. The medical cause of death was given as:
la) Suspension by ligature (Hanging)
The conclusion of the inquest was a narrative which read as follows:
Oliver Ford was under the care of the mental health service at the time of his
death. He had been triaged but no formal risk assessment had been carried out.
He was found hanging from a tree in woodland his intention is unknown.
4 | CIRCUMSTANCES OF THE DEATH
Oliver Ford had a diagnosis of social anxiety disorder with substance misuse. In the
week leading up to his death he had taken heroin and amphetamines. On 13" and 14"
August he began to express paranoid thoughts. On the 14" August he was triaged by
the Primary Care Liaison Service, a risk assessment was not carried out. This was
confirmed in evidence by both the registered mental health nurse and indeed the
consultant psychiatrist who provided an overview of Oliver’s care. At the end of the
triage the plan was to speak to him again on Monday, he was advised not to take drugs
over the weekend and was provided with the details of the intensive support team. On
15! August he was reported missing and on 16" August he was found dead by a
member of the public hanging from a tree at Norton Wood, Clevedon.
Iwas told in evidence by the registered mental health nurse that the PCLS only operate
from Monday to Friday. Her plan would have been to ring him the next working day as
that was Monday that’s why the Monday was put in the plan.
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 two areas of concern which were raised at the inquest were in relation to the
triaging process and specifically assessing a person’s risk during that triage together
with the cover for the PCLS over weekends.
| therefore indicated at the conclusion of the inquest that | would be writing to Avon &
Wiltshire Mental Health Partnership NHS Trust asking that they consider the following
matters of concern.
4. That there is a further review of the telephone triage process to specifically
consider including a risk assessment. | was made aware that the triaging
process has been reviewed but was not advised of any review to the risk
assessment process itself.
2. In addition that any risk assessment at all, whether it is formal, informal or
indeed based on clinical judgment alone following the triage, is always
documented in the Rio notes.
3. | am aware that you have considered extending the PCLS service into Saturday.
| would ask that you look at cover for the PCLS service over the weekend, so for
example any need to follow up a patient the next working day even if itis by
phone is actioned by another team and not left because the triage occurs on a
Friday.
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.
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report,
namely by 30" September 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.
{8 | COPIES and PUBLICATION
| have sent a copy of my report to the Chief Coroner and to the following Interested
Persons which include the family of Mr. Ford and Avon & Somerset Constabulary.
| 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.
45 August 2016 eee Coroner
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.
Maria Voisin Senior Coroner The Coroner's Court The Courthouse Old Weston Road Flax Bourton BS48 1UL 29 September 2016 Dear Ms Voisin Avon and Wiltshire INHS| Mental Health Partnership NHS Trust Chief Executive's Office Jenner House Langley Park Chippenham Wiltshire SN15 1GG Tel:(01249) 468023 | am writing in response to the Prevention of Future Death report you issued to this Trust following the inquest into the death of Oliver Ford deceased. The response has been prepared by EEE. the Quality Director for North Somerset Services. 1. Following the review, the telephone triage process now includes the access trigger tool which is a trust wide tool that requires every clinician to ask in depth questions about risk, In essence it is a risk assessment which will indicate an immediacy of response. The access trigger tool will assess: Referrer concerned about Family members/carer concerned about: Referrer requesting: Lack of corroborative information Two or more previous contacts (by any means) to AWP services from other sources about this person Patient previously known to AWP services Previous history of significant suicide attempts or risks Previous history of significant suicide attempts or risks Adverse life-event or unresolved factors reported to be associated with suicidal ideation or risk to others — e.g. pending court appearance Recent serious self-harm, especially if life-threatening or planned Co-morbid alcohol and/or drug use judged to have adverse impact on mental state and level of risk Previous history of self-harm Substance and alcohol use Risk summary Continued... — Chair Trust Headquarters Chief Executive Jenner House, Langley Park, Chippenham, SN15 1GG ‘Hayley Richards ‘We are a teaching, learning and research trust, we aim to inform you about relevant opportunities, unless you tell us otherwise.’ Pending or recent discharge from inpatient mental health care or other transition Admission history Further detail relating to known risk information 1.1.1. Clinical information regarding current presentation: 4.1.2 High risk clinical syndrome - depression, adjustment disorder, psychosis, emotionally unstable personality disorder 1.1.3 Any Safeguarding issues 1.1.4 Impulsivity 4.1.5 Currently, or very recently, in a high risk situation - e.g. threatening to jump from a height, located in a high risk setting such as a railway line 1.1.6 Referrer reports any kind of difficulty in engaging with patient 4.1.7. If known to mental health services, care coordinator expresses concerns regarding risk and requests temporary allocation to a more intensive treatment pathway 1.1.8 There are now 2 clinicians on duty at PCLS until 8.00pm Monday to Friday, the service transfers at 8pm, to the Intensive Support Team that operates 24 hours per day. 2. Following the Access Trigger Tool assessment the clinicians are required to document on RIO a full rationale for decision making based on the collateral information gathered from the Access Trigger Tool. This is being used in all Access referrals. This process is audited by the PCLS Team Manager on a monthly basis. 3. For all urgent and emergency referrals the PCLS service will be covered by the Intensive Support Team (outside of its normal operating hours which are Monday to Friday 08.00-20:00). The Intensive Support Team operates 24 hours per day 365 days per year. Any action that requires follow up outside PCLS working hours (including bank holidays and weekends) will be handed over to the Intensive Support Team for action. If you require further information, please do not hesitate to let me know. Yours sincerely RE : <i Medical Director on behalf of Dr Hayley Richards Chief Executive
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