Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0409, written 14 Nov 2016. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 14 Nov 2016 |
|---|---|
| Reference | 2016-0409 |
| Deceased | Martyn Watkins |
| Coroner | Dr Peter Harrowing |
| Coroner area | Avon |
| Category | Suicide (from 2015) · Mental Health related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. 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. Care Quality Commission
2.
3. Avon and Wiltshire Mental Health Partnership NHS Trust
4. Chief Coroner
, daughter of the Deceased
1
CORONER
I am Dr. Peter Harrowing, LLM, Assistant Coroner, for the coroner Area of Avon
2
CORONER’S LEGAL POWERS
I 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 6th April 2016 I commenced an investigation into the death of Mr. Martyn Watkins
aged 65 years. The investigation concluded at the end of the inquest on 11th
November 2016. The conclusion of the jury was that the medical cause of death was
I(a) Hypoxic brain injury; I(b) Hanging, and their conclusion was that of:
“Suicide - facilitated by access to means, resulting from inadequate checks to remove
ligature risks from his person and a failure to identify fundamental risks in the
environment”.
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CIRCUMSTANCES OF THE DEATH
During December 2015 Mr. Watkins suffered a deterioration in his mental health
related in part to concerns he had with the health of close members of his family and
his own retirement from employment as an accountant. He came under the care of
the mental health services and was seen by members of both the Primary Care
Liaison Service (PCLS) and the Intensive Support Team (IST). Mr. Watkins had
contact both by face-to-face visits at home and also telephone contact with members
of those teams on a regular basis. The plan was to try and support Mr. Watkins and
his family at home so as to facilitate his recovery. However, he developed suicidal
ideation and required two brief hospital admissions one following an intentional
overdose of medication.
His family became increasingly concerned at the risk Mr. Watkins posed to himself
from suicide such that they removed all medication from his home, including that of his
wife, and gave him doses of his medication as required. However, the family were
finding it extremely difficult to manage the situation and keep Mr. Watkins safe. There
was no real improvement in his presentation and there were significant concerns
regarding his thoughts of suicide. By March 2016 the family reported they were at
their ‘wits-end’.
On 22nd March 2016 Mr. Watkins daughter contacted, via social media, the Associate
Practitioner on Aspen Ward, Callington Road Hospital which is part of the Avon &
Wiltshire Mental Health Partnership NHS Trust (‘the Trust’) in an attempt to seek any
assistance to help her father. These two individuals knew of each other through a
mutual third party.
The Associate Practitioner contacted Mr. Watkins’ daughter and offered to speak with
a consultant psychiatrist on Aspen Ward. The Associate Practitioner duly spoke with
the consultant psychiatrist on the morning of 23rd March 2016 who in turn agreed to
provide a second opinion if appropriate. Mr. Watkins’ daughter was contacted again
that morning by the Associate Practitioner seeking further information. However, by
this time a Mental Health Act (MHA) Assessment had been arranged and this was
planned for that same day.
On 23rd March 2016 the Associate Practitioner explained the situation to the Ward
Manager of Aspen Ward who agreed that Mr. Watkins could be admitted to that ward if
his admission and detention was required. The Ward Manager contacted the IST
advising that Mr. Watkins could be admitted to Aspen Ward subject to a bed being
available.
The MHA assessment was undertaken as planned by the Approved Mental Health
Professional (AMHP) and two consultant psychiatrists and it was determined that he
needed to be admitted to hospital under s.2 Mental Health Act 1983. The Section 12
approved psychiatrist told the Inquest that Mr. Watkins was at high risk of suicide and
at risk of impulsive acts.
During the afternoon of the 23rd March 2016 the ward was advised that the second
registered mental health nurse due to work the late shift that day was sick and as a
result that shift would be staffed by only one Registered Nurse (herself undergoing her
preceptorship) together with the Associate Practitioner, Health Care Assistants and a
student nurse. Prior to the Ward Manager going off duty at around 17:30 hours the
Registered Nurse advised the Ward Manager that she would not be able to accept any
new admissions during her shift since she would be the only Registered Nurse on
duty.
Sometime later the Associate Practitioner advised the Registered Nurse that Mr.
Watkins was going to be admitted to the ward and he arrived at around 20:20 hours.
The Registered Nurse was unsure what had been agreed between the Associate
Practitioner and the Ward Manager with regard to Mr. Watkins’ admission to the ward.
However, the Associate Practitioner advised that she was able to admit him to the
ward.
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On his arrival on the ward Mr. Watkins’ stated he wished to go directly to his room and
he was taken there by the Associate Practitioner. The Registered Nurse told the
Inquest that she did not see Mr. Watkins at all during her shift as she was mostly
attending to duties in the office. The AMHP also attended Aspen Ward and saw the
Registered Nurse but did not speak to the Associate Practitioner.
Aspen Ward is a ward designed for older patients and Mr. Watkins was admitted to a
room intended originally for those patients requiring palliative care. In the room, in
addition to the service user’s bed, was a fold up bed constructed of an aluminium
frame and wooded slats, which was intended for use by a relative of the service user.
This bed was fixed and located within a wooden cupboard and folded flat against the
wall. The bed could be pulled down when required for use. The cupboard was
believed to have been locked although no witness at the Inquest confirmed they had
checked the cupboard was locked at the time. Some witnesses from the ward were
unaware there was such a bed within this cupboard.
The Associate Practitioner went through the admission procedure with Mr. Watkins.
She told the Inquest that she went through his bag carefully noting its contents and
removed some items she considered could be potentially used as a ligature. The
Associate Practitioner, in evidence, told the court that she did not enquire of Mr.
Watkins as to what items he had on his person nor did she carry out any search of Mr.
Watkins for items which might have posed a risk to him. She told the court that she
did not know he was wearing a belt and therefore Mr. Watkins retained his belt.
Mr. Watkins was placed on 10-minute observations by the Associate Practitioner.
Following the later incident the observation chart went missing and has not been
found. Those witnesses, who had carried out some of the observations, who gave
evidence at the Inquest confirmed they carried out their observations at the required
times. During his time on Aspen Ward it appears Mr. Watkins remained fully clothed at
all times. He was seen overnight to be sleeping on his bed and was fully clothed.
Overnight he was seen by the duty doctor to be clerked on to the ward and for his
medication to be prescribed. No physical examination was carried out at that time.
The following morning, the 24th March 2016, Mr. Watkins was seen by the consultant
psychiatrist who did not notice the belt. He was also seen by a ward doctor who
conducted a physical examination including an abdominal examination. That doctor
did not give evidence at the Inquest.
One Healthcare Assistant (1) who carried out some of the 10-minute observations
reported that Mr. Watkins would not speak and did not make eye contact. Another
Health Care Assistant (2) was able to engage in some conversation with Mr. Watkins.
At around 12:15 hours the Health Care Assistant (2) saw Mr. Watkins in his room
inviting him to the dining room for lunch. Mr. Watkins declined and also did not wish to
have any food in his room.
Shortly after 13:00 hours Health Care Assistant (2) went to Mr. Watkins’ room for a
10-minute observation. He saw the doors of the cupboard containing the bed open
and Mr. Watkins hanging from his belt used as a ligature which had been secured to
the top aluminium rail of the bed. He sounded the site-wide alarm and lowered Mr.
Watkins to the floor. Other members of staff quickly attended and CPR was
commenced. The paramedics and air ambulance were summoned. Mr. Watkins was
unconsciousness and he was taken to Southmead Hospital, Bristol. Despite treatment
on the Intensive Care Unit he never regained consciousness and died in hospital on
1st April 2016.
The witnesses who attended the Inquest stated they had not seen Mr. Watkins
wearing his belt. Police officers and CSI attended Aspen Ward. A police officer states
he was shown the observation chart at that time by the Ward Manager and confirmed
there were entries at the appropriate times. The doors of the cupboard containing the
bed did not appear to have been forced. The police officers were satisfied there was
no third party involvement in Mr. Watkins’ hanging.
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During the course of the Inquest the evidence revealed that:
1. There was no documented discussion between teams of the purpose of admission
and concerns about risk in the community.
2. The room used to accommodate Mr. Watkins was inappropriate and unsafe given
his high risk suicide.
3. There had been no risk assessment of the cupboard and fold-up bed with respect
to ensuring the cupboard was secure and the presence of ligature points.
4. On arrival on the ward the standard procedure for admission was not followed with
no documentation of the admission by a registered professional.
5. No enquiries were made, and no proper search was made, of Mr. Watkins to
ensure he had no items on his person which could pose a risk to him although
items in his bag had been removed.
6. There was a lack of communication of the specific risks in the progress notes and
72-hour care plan created by the Associate Practitioner.
7. The risk of hanging was not considered as Mr. Watkin’s had only expressed
thoughts of taking an overdose before admission to hospital.
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 care and treatment provided by the Trust to Mr. Watkins should be reviewed
at the earliest opportunity in the light of the findings of the jury at the Inquest and
the Trust’s own internal management report and root cause analysis report.
(2) The CQC should satisfy themselves that any and all deficiencies in the care
provided to Mr. Watkins and generally on Aspen Ward have been identified and
addressed.
(3) The CQC should satisfy themselves that an appropriate timetable and action plan
are in place to ensure any outstanding issues on Aspen Ward relating to the safe
care and treatment of service users are addressed at the earliest opportunity.
(4) The CQC should satisfy themselves that the arrangements and facilities for the
provision of care and treatment of service users on Aspen Ward, now and in the
future, are such as to ensure those service users can be provided with safe care
and treatment.
6
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe your
organisation has the power to take such action.
7
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report,
namely by 9th January 2017. 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.
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8
COPIES and PUBLICATION
I have sent a copy of my report to
the Avon and Wiltshire Mental Health Partnership NHS Trust
daughter of the deceased, and
I shall send a copy of your response to Ms. Watkins and the Avon and Wiltshire Mental
Health Partnership NHS Trust
I have sent a copy of my report to the Chief Coroner.
I 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.
9
14th November 2016 !
Assistant Coroner
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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.
HSCA Citygate Gallowgate Newcastle upon Tyne NE1 4PA HM Senior Coroner The Coroner’s Court The Courthouse Old Weston Road Flax Bourton BS48 1UL 3 February 2017 Care Quality Commission (CQC) Our Reference: Your Reference: Dear HM Coroner Prevention of future death report following inquest into the death of Mr Martyn Watkins. Thank you for your letter dated 14 November 2016, enclosing the above Report. We are also grateful for the extension of time granted for this response (until 6 February 2017). As you are already aware the Provider which is registered with CQC and has overall responsibility for services provided at the relevant location (Callington Road Hospital) is Avon and Wiltshire NHS Partnership Trust. CQC became aware of the sad death of Mr Watkins on 16 May 2016, when the Trust shared a management report with us through an online information sharing system. The report had been uploaded to the system on 12 May 2016. This was received by the lead CQC inspector for the Trust. We noted that Mr Watkins had been detained under Section 2 of the Mental Health Act (MHA). We had not received a statutory notification of a death of a detained patient so we contacted our MHA office in Nottingham to check. Once it was confirmed that we had not received notification we called the MHA Administrator at the Trust to ask why we had not been notified. We were told that Mr Watkins had been discharged from his section on transfer to Southmead Hospital. At the time we planned to inspect older adults’ inpatient services between 16 and 27 May 2016 as part of our comprehensive inspection programme. We asked the inspector leading the team to follow this up when they visited Aspen Ward. During the inspection we found that the Trust had learnt from the death and implemented changes to manage future risks on Aspen Ward. However, the rating for the overall core service (older people’s mental health inpatient wards) was “requires improvement” because: • There were not sufficient staff numbers to meet the needs of people using the services. There was a high level of qualified nurse vacancies on some wards with no psychology input. • Levels of emergency response training and practical patient handling training were low. • Staff did not consistently adhere to Mental Health Act legislation and standards described in the Mental Health Act (MHA) 1983 code of practice. • Staff completed mental capacity assessments but did not document decision specific assessments. • Staff were inconsistent when reporting of incidents. • Staff did not always follow agreed actions or involve patients in care plans. • Staff did not all use the health of the nation outcome scales for over 65s. They were not consistently monitoring patient’s outcomes. • Multidisciplinary team meetings did not all have a full range of professions. • The standard of the environments was variable. They were not all “dementia friendly”. Safety alarms were of variable quality or were not available. Some bedroom windows did not protect patient’s privacy and some patients slept in dormitories. Our response to the matters raised in the Regulation 28 letter is as follows: 1. As a regulator CQC has both criminal and civil enforcement powers. There are two primary reasons why we may use our enforcement powers. First to protect people who use regulated services from harm and the risk of harm and to ensure they receive health and social care services of an appropriate standard. Secondly to hold providers to account for failures in how the service is provided. Further and more specific detail is included in our published Enforcement Policy, a copy of which is available free of charge on our web-site (http://www.cqc.org.uk/content/enforcement-policy) 2. The civil enforcement powers are aimed at ensuring that any ongoing risk to patients, such as those detailed in the Regulation 28 Report are appropriately identified, and that where risks are still found to exist that we as a regulator take proportionate action to ensure that the Provider becomes compliant with the relevant legal requirements which ensure patient safety. Such action can be anything from formal ‘Requirement Notices’ / ‘Warning Notices’ to imposing urgent conditions on the Registration of a Provider and in extreme circumstances suspending or cancelling the Registration of a Provider. In relation to this particular Trust we are exercising our statutory powers to request information and documentation to identify and determine the level of risk to patients. As part of this process we have also already exercised our statutory powers of Inspection (on 10 January 2017) and we are currently liaising with the Trust to ensure that patients are properly protected. The Inspection and the associated regulatory actions are looking at not just the matters identified in the Regulation 28 Report but also wider issues which may impact on safe care and treatment for patients. 3. The criminal enforcement powers which we have are aimed at holding Providers to account where there has, for example, been a failure on the part of a Provider in terms of safe care and treatment, and where those failure(s) have then resulted in avoidable harm to a patient (whether physical or psychological), or alternatively where the failure(s) expose a patient to serious risk of such harm. We do not have regulatory powers to take action against individuals (e.g. clinical / healthcare staff) where there are individual failings (as those would be dealt with by other professional bodies). However this does not mean that we will not look at individual failings to determine why they occurred and specifically consider whether a Provider could/should have taken action to ensure that such failings were avoided altogether. In relation to this particular Trust we have noted that the indication from the Trust in the Root Cause Analysis (RCA) Investigation Report (Reference: 2016/8370) appears to be that the sad death of Mr Watkins was caused by an individual failing to remove from his possession a belt. Whilst we are grateful to receive the RCA as well as the ‘Management Report on Red Graded Incidents dated 31/03/2016’ from the Trust, we are reviewing for ourselves the circumstances which led to the sad death of Mr Watkins and in accordance with our regulatory remit will make our own judgments in that regard. We are happy to keep HM Coroner updated on the progress of our regulatory actions should HM Coroner deem this to be appropriate. Should you require any further information please do not hesitate to contact us: By email: Cc’d to: By post: HSCAfurtherinformation@cqc.org.uk Care Quality Commission Citygate Gallowgate Newcastle upon Tyne NE1 4PA Please include the reference number MRR1-3078722466 on all correspondence. Thank you in advance for your assistance. Yours sincerely Head of Inspection Hospitals (Mental Health South Central)
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