Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0322, 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 | 2016-0322 |
| Deceased | Louise Turner |
| Coroner | Lydia Brown |
| Coroner area | Exeter and Greater Devon |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Devon 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)
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
1. The Chief Executive
NHS Northern Eastern and Western Clinical Commissioning Group
Newcourt House
Newcourt Drive
Old Rydon Lane
Exeter
Devon
EX2 7JQ
2. The Chief Executive
Ministerial Correspondence and Public Enquiries Unit
Department of Health
Richmond House
79 Whitehall
London
SW1A 2NS
3. Melanie Walker
Chief Executive
Devon Partnership Trust
Wonford House Hospital
Dryden Road
Wonford
Exeter
Devon
EX2 5AF
4 CORONER
lam Mrs Lydia Brown, Assistant Coroner for the Exeter and Great Devon District
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 2™ July 2014 | commenced an investigation into the death of Louise Turner
otherwise known as Abigail Jessica Jackson. The investigation concluded at the end of
the Inquest on 16 May 2016. The conclusion of the Inquest was:
Medical cause of death
1({a) Helium Asphyxiation
Conclusion — Suicide contributed to by neglect
CIRCUMSTANCES OF THE DEATH
Louise died on 27 June 2014 from inhalation of helium at 29 Gabriel Court, Commercial
Road, Exeter. At the time she was receiving ongoing treatment for a serious mental
health illness and had recently been discharged home after a lengthy in-patient stay. It
had been agreed by Louise that the hospital would take custody of and destroy the
helium she had obtained, but as there were no effective plans or policies in place,
instead it was returned to her the day before she died.
The clinicians responsible for Louise's care were fully aware of the potential
psychological impact this would have and her previous high risk, self- harming behaviour
patterns. Furthermore, Louise's feelings of abandonment were increased as no physical
care arrangements were in place due to poor communication and the promised mental
health contacts were not conducted in accordance with the care plan and her needs.
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) The Devon Partnership trust had no adequate mental health care for Louise
after she was discharged. There was inadequate contact and no explanation at
Inquest as to why this had not taken place.
(2
The duty system arrangements and buddying system referred to at Inquest were
not effective or robust and need to be reconsidered in the light of the outcome of
this case.
(3
Roo
There was a suggestion at Inquest that the patients themselves were expected
to be in charge of making contact. In cases of severe mental heaith, this does
not appear to be appropriate or realistic, and the Devon Partnership Trust
should reconsider this and/or the training of their staff who hold this belief.
(4
pes
There are no female intensive care beds for psychiatric patients in Devon. This
does not match the desired parity of mental health care with physical health
care. Devon Partnership Trust needs to consider future planning and provision
to ensure the needs of patients can be met.
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and | believe you and your
organisation 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 November 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.
Your respohse must contain details of action taken or proposed fo 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:
Mother of Deceased)
(Devon Partnership Trust)
ma... Partnership Trust)
Bond Dickinson)
(Adult Social Care)
(Principal Social Worker)
HE (Trust Solicitor - RD&E Exeter)
| 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 b’ igf Coroner,
Pate ( ‘ IG) Like 201 Y signed anatase gt ownensacastanreeanens avovseas
County Hail
Topsham Road
EXETER
Devon EX2 4QD
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.
HEALTHY NHS Ivin Ng healthy Northern, Eastern and Western Devon ~ ; Clinical Commissioning Group Private and confidential 2" Floor the Annexe Ms L C Brown County Hall Exeter and Greater Devon Coroner’s Office Topsham Road Room 226 Exeter Devon County Hail EX2 4QL Topsham Road Exeter EX2 4QD 01 November 2016 Dear Ms Brown Re: Louise TURNER Deceased D.O.D 27/06/2014 Inquest held on 16 May 2016 at County Hall, Topsham Road, Exeter Regulation 28 Report | am writing to you in response to your letter dated 07 September 2016 to NHS Northern, Eastern and Westem Devon Clinical Commissioning Group (the CCG). Please see below the CCG response to the matters of concern identified in the Regulation 28 report. Matters of concern 1 - 3 The CCG is responsible for the commissioning of care including monitoring the quality and safety of the services it commissions. As such the following outlines the expected service response from Devon Partnership NHS Trust and the arrangements for monitoring. In accordance with the current service specification and contractual agreement for the provision of secondary mental health service, we would expect that Devon Partnership NHS Trust adhere to safe service delivery which includes timely, responsive and personalised interventions. We would expect that there are robust care planning processes in place in line with Care Program Approach principles, and that follow-up processes are in place to support seamless and safe discharge for every individual moving from an acute stay in hospital. Our expectation is that individuals will be offered regular review and timely follow-up including services for Assertive Outreach where appropriate. Information sharing is pivotal to this process and a-multi-disciplinary approach is expected, including engagement with family, carers and significant others where appropriate. Chair: Le Chie! Oficer: Newcourt House, Old Rydon Lane, Exeter, EX2 7JU Tel. 01392 205205 www.newdevonceg.nhs.uk We expect that operational plans and protocols are subject to regular review to ensure that high standards of care and supervision remain in place and that there is robust workforce compliance. With regard to serious incident investigations, specific actions are identified from the report recommendations in order to mitigate against a re-occurrence. The CCG requires assurance that these actions are progressed and implemented and that learning is embedded within provider organisations. All actions identified by Devon Partnership NHS Trust in serious incident reports are recorded by the CCG safety systems team, and followed up by the patient safety and quality lead through routine meetings with the serious incident team at the Trust to review closed actions and the associated evidence of completion. Matters of concern 4 Following the publication of the Mental Health Crisis Care Concordat and the Care Quality Commission (CQC) inspection report into Devon Partnership NHS Trust in February 2014, it was identified that the lack of a Psychiatric Intensive Care Unit (PICU) in Devon was a significant deficit to the mental health acute care system. This was further magnified by the publication of the Crisp Report (Crisp, N., Smith, G. and Nicholson, K. (Eds.) Old Problems, New Solutions — Improving Acute Psychiatric Care) which identified serious issues with the use of out of area placements for people experiencing acute mental ill health. The CCG led an option appraisal including all the Peninsula commissioners and providers, where it was identified that a PICU was required in Devon. This proposal was considered by the CCG and it was concluded that the revenue funding to support the operation of a PICU was available within the Devon Partnership NHS Trust contract and that they should develop a plan for the design, construction and operation of a PICU within Devon to ensure provision across Devon, Plymouth and Torbay. A proposal to build a local PICU facility was reviewed and agreed by the CCG Executive Committee on 20 July 2016 with the Governing Body confirming their support for implementation for a local, 10 bedded PICU on the Wonford Hospital site, adjacent to the Cedars Mental Health Acute Unit by April 2018. Current PICU provision is sourced by Devon Partnership NHS Trust via a contractual arrangement with provider organisations in both London as well as Weston-Super- Mare. The proximity of this provision informed recent commission decision and aligned to our commitment to deliver care closer where people live. The CCG is committed to a jointly shared program of actions aligned to the Mental Health Crisis Care Concordat, along with other partner and stakeholder organisation including NHS providers and Devon and Cornwall Police. Through strong collaboration and a robust local governance framework, a series of improvement measures are Chair: Chief Officer: Newcourt House, Old Rydon Lane, Exeter, EX2 7JU Tel. 01392 205205 www.newdevonccg.nhs.uk being enacted to ensure multi-agency, safe responses for individuals experiencing mental health crisis. | hope that this letter answers your concerns, however should you have any further questions please do not hesitate to contact me. Yours sincerely Chief Nursing Officer/Caldicott Guardian NHS Northern, Eastern and Western Devon Clinical Commissioning Group RECEIVED 0 2 NOV 2016 chai: Chief 0c Newcourt House, Old Rydon Lane, Exeter, EX2 7JU Tel. 04392 205205 www.newdevonccg.nhs.uk
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