Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0319, written 7 Sep 2016. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 7 Sep 2016 |
|---|---|
| Reference | 2016-0319 |
| Deceased | Christopher Jones |
| Coroner | John Gittins |
| Coroner area | North Wales (East and Central) |
| 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 |S BEING SENT TO:
Chief Executive, BCUHB, Ysbyty Gwynedd, Penrhosgarnedd, Bangor, Gwynedd LL57
2PW
4 CORONER
lam JOHN ADRIAN 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 the 16" of June 2015 | commenced an investigation into the death of Christopher
Glyn Jones (DOB 6.7.88, DOD 11.6.15). The investigation concluded at the end of the
inquest on the 2 of September 2016 and | recorded a narrative conclusion in the
following terms :-
“Christopher Glyn Jones was a twenty seven year old man who was suffering from a
mental illness for which he was receiving care and treatment from the Betsi Cadwaldr
University Health Board.
Although the individual care provided to him by members of staff reflected their desire to
act in his best interests, his overall treatment was unsatisfactory due to delays in the
formulation of treatment plans and risk assessments and failures in the provision of
intended treatments and inadequate escalation of concerns at a time of significant
decline in his mental health, although it cannot be said, even on the balance of
probabilities, that this resulted in his death which was due to a deliberate act of self
harm”
4 | CIRCUMSTANCES OF THE DEATH
The Circumstances of the death are that the deceased died as a result of placing himself
into collision with a train whilst under the care of the Community Mental Health Team
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. Evidence at the inquest indicated that the deceased was discharged from
inpatient treatment on the 6" of January 2015 but his Care Treatment Plan was
not completed until the end of April 2015 and that this would then only require
review within a period of twelve months from that date, as a result it could have
been the case that a patient who had recently been sectioned and treated as an
inpatient may not then be seen by a consultant psychiatrist for a period in the
region of sixteen months.
2. Furthermore evidence indicated that although additional resources were
currently being made available and deployed for Mental Health within BCUHB,
there was also an increasing demand on the service and as a result there may
still be deficiencies of service, for example in providing acceptable levels of
cover for staff at times of sickness/holidays etc.
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 2.4 November 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 — Leigh Day Solicitors (Representatives of the family of the deceased)
lam 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.
7 September 2016 {SIGNED BY CORONER]
AW FA)
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, Bwrdd lechyd Prifysgol Ysbyty Maelor Wrecsam, Wrecsam, . LL13 7TD BeisiCadwaladr University Health Board Heddfan AMHU, Wrexham Maelor Hospital, Wrexham, LL13 7TD Mr J Gittins Ein cyf / Our ref: H M Coroner North Wales . . County Hall Eich cyf / Your ref: pynnstay Road Ffén / Telephone: 01745 586399 Ruthin Denbighshire Bofynnweh am / Ask FY LL16 1YN . Dyddiad / Date: 31% October 2016 Dear Mr Gittins Re: Regulation 28 Response re Christopher Glyn Jones | write in response to the Regulation 28 issued on 7 September 2016 as a result of the inquest into the death of Mr Christopher Glyn Jones. The Mental Health (Wales) Measure 2010 Legislation was designed to improve access to and the delivery of mental health care in primary and secondary care settings and to extend the availability of independent advocacy. The supporting Code of Practice gives clear guidance to mental health service providers in Wales in meeting their obligations under Part 2 or the Measure, ie the coordinator of and care planning for secondary mental health service users. In relation to your first matter of concern in that Mr Jones was discharged from inpatient treatment on 6 January 2015 but his Care and Treatment Plan was not completed until the end of April 2015 and then that this would only require review within a period of twelve months from that date. Chapter 6 of the MHM Code of Practice reinforces the importance of monitoring and review, and the requirement to reflect any changes in order that effective care and treatment is provided. It states there should be “ongoing assessment of the patient's mental health related needs, along with the nature and degree of need and risk they are currently presenting’. In relation to the triggers to prompt review it states “a review must be held as a minimum at least once in any twelve month period. However, reviews should be needs led and should be held as frequently as required. For example, when the care coordinator becomes aware of any significant changes to the patient’s health or social needs or identified risks”. To reaffirm the requirements of responsibilities under the Mental Health (Wales) Measure, a series of training events have been organized. These training events are mandatory for all staff within Mental Health and Learning Disabilities, and is delivered at Levels 1, 2 and 3. 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 > J 430 AZO) Bwrdd lechyd Prifysgol Betsi Cadwaladr University Health Board = > r m n A copy of the training flyers and training dates are attached. Additionally MHM administrators send a report to managers of all CTPs due for review, 3 months in advance with a view to avoiding any CTPs becoming out of date and patients have reviews in a timely manner. In relation to your second area of concern relating to the need to provide acceptable levels of cover for staff at times of sickness/holidays etc. The Division has produced a multi-agency document “The Role of County Wide Mental Health Teams in Delivering Community Mental Health Services”, which is a supporting document to the MHM Code of Practice, and sets out the local requirements. This first became operational in August 2013 and has been reviewed regularly. A recent addendum to this protocol reminds staff that “Care and Treatment plans are the responsibility of the CTP coordinator or their associate. In the absence of a CTP coordinator, or associate, it is the Deputy County Manager's responsibility to ensure that any CTPs which are due for review are appropriately updated. In practice this may mean either undertaking reviews themselves or delegating the review out as appropriate, depending on the client and the situation. Any difficulties with completing this due to capacity issues must be escalated to senior management, via the County Manager and Locality Manager. Copies of the Protocol and addendum are attached. Regular audit of MHM compliance is reported divisionally on a monthly basis to local managers and the divisional Quality, Safety and Experience Committee, and corporately to the Mental Health Act Committee quarterly. Yours sincerely | Cyfarwyddwr lechyd Meddwl ag Anabledd Dysgu Director of Mental Health and Learning Disabilities
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