Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0425, written 29 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 | 29 Nov 2016 |
|---|---|
| Reference | 2016-0425 |
| Deceased | Robert Lloyd |
| Coroner | Emma Carlyon |
| Coroner area | Cornwall and Isles of Scilly |
| Category | Alcohol, drug and medication related deaths · Community health care and emergency services related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
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 Robert Lloyd deceased REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Mr Guy Pink, Chief Executive of Addaction 4, 2. Commissioning Manager Drug and Alcohol Action Team 3. Senior Partner of St Mary’s Health Centre, St Mary’s, Isles of Scilly CORONER | am Senior for the coroner area of Cornwall and Isles of Scilly 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. INVESTIGATION and INQUEST Robert Lloyd died on 30" July 2016 at the Royal Cornwall Hospital after being airlifted from the Isles of Scilly. A post mortem was undertaken and the cause of death was found to be due to drowning. A significant amount of alcohol was found on post mortem toxicology (280mg/100 mL). An inquest was opened on the 15" August 2016 with the inquest heard on the 19" October 2016. CIRCUMSTANCES OF THE DEATH Robert Lloyd went swimming in the sea at Porthcressa Beach, St Mary's, Isles of Scilly with a friend on 30" July 2016 at around 17.10 pm. They swam for around 20 minutes when Robert returned to the shore. When he was waist deep, he was seen to stop moving/swimming and float face down in the water. He was pulled to the shore and resuscitation attempts were commenced. The air ambulance arrived and transferred him to the Royal Cornwall Hospital, Treliske, Truro where he was recognized dead. He was alcohol dependent and post mortem blood alcohol analysis found the blood alcohol (280 mg/100 ml) at a level which was likely to have affected his cognition. 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. — At the inquest written evidence was read from the GP and Addaction as to Mr Lloyd’s abuse of alcohol and the difficulty in providing supportive treatment for alcohol abusers on the Isles of Scilly. It was acknowledged that due to the island’s location and with limited air and boat services after the termination of the helicopter service some years ago, the support was limited. This has meant that the service users on the Islands have had limited face to face support and had to rely of video link support due to the inability of alcohol support professionals to travel to the Islands in bad weather. This had led to a difficulty in engaging with this group of users. Mr Lloyd’s mother, at inquest explained how the reduction in service (on the termination of the helicopter service) had affected her son and made it more difficult for him to control his drinking habit especially on a small island with a strong alcohol drinking culture. In the past he had access to face to face alcohol reduction workers and he was able to attend (for a small travel fee) the Alcoholics Anonymous group on the Main Land. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you AND/OR your organisation have the power to take such action. To review the provision of support to excess alcohol users on the Isles of Scilly with a view to preventing future deaths YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 25" January 2017. |, 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 Interesting Person: ne have also sent it to The Council of the Isles of Scilly and EEE who may find it useful or of interest. | 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. [DATE] [SIGNED BY CORONER] 29/11/2016 Cligaboetl Crrnne Geclysr
2 responses 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.
Dr E E Carlyon Senior Coroner for the County of Cornwall The new Lodge Newquay Rd Penmount TRURO TR4 9AA Helford House May Court Truro Business Park Threemilestone TR4 9LD Tel: Email: Date: 24TH January 2017 Dear Dr Carlyon, Re: Regulation 28 report Mr Robert Lloyd I am writing in my capacity as commissioner of alcohol and drug treatment services for Cornwall & Isles of Scilly, in response to your letter dated 29th November 2016, issuing a Regulation 28 report regarding the death of Mr Robert Lloyd 30th July 2016. Your report asked me to review the provision of support to dependent drinkers on the Isles of Scilly with a view to preventing future deaths. Before I do so, I would like to say how sad we were to learn of Robert’s death. It had already been recognised that it was far too challenging for individuals to secure sufficient help on the islands with drug and alcohol problems and we were engaged in a review process, with the islands, to ascertain how best we all might meet peoples’ needs within the available resources. CIOS DAAT committed to undertaking a needs assessment with IOS during 2016-17. A member of our team has been working with the Council for the Isles of Scilly, health partners, the police and Addaction to identify ways in which we could all improve provision. Initial work has included interviews with key health and social care personnel, staff working in housing, licensing, school and police. The public survey conducted in conjunction with IOS Healthwatch received more than 30 responses. Feedback and anecdote estimate high prevalence of problematic drinking on IOS with a degree of disruption to the community including anti-social behaviour and visible health burdens (see attached report update October 2016). In addition, a joint improvement plan is in place with Addaction, the commissioned provider of specialist drug and alcohol treatment services for IOS (also attached), who had also produced a report looking at service delivery to the islands. Both reports support the view that the community needs more support and a more visible therapeutic presence on the islands to encourage more islanders to access advice, information and treatment for alcohol and drug dependency. A new Adults Recovery Co-ordinator has been appointed, with a brief to be more proactive. He has commenced fortnightly visits to the islands. He will also have back/replacement cover for sickness and annual leave, will establish a regular AA meeting on the islands, to replace the need for islanders having to travel to the mainland for this, and provide support for affected others (families and friends). YZUP continue to provide support and advice for families and young people. However, there continue to be very low numbers engaging by comparison to the level of need described and the purpose of a stakeholder meeting is to explore means of more assertively identifying and engaging those who would benefit from earlier help. There is also always the challenge of delivery from the mainland when the weather obstructs. Therefore, a longer term view has been to train a wider range of professionals and residents to be better able to support people with dependency issues on the islands. In summary response: 1. The contract we hold with Addaction requires a minimum of fortnightly island visits in 2017-18. This to deliver interventions which will include face-to face contact with the Recovery Co-ordinator; a drop-in session; IOS specific resources; access to both home detox and community hospital detox; appropriate prescribing for medical problems; access to volunteer supporters; and group therapy. Visits can be supported, but not replaced, by Skype. Cover will be made available for any sickness or annual leave. Some of these services will be made available on the off islands, but this has yet to be worked up. 2. An AA and NA meeting will be delivered on the islands rather than having to transport people to the mainland for this purpose. 3. Where there has been a hospital admission on the mainland, RCHT Alcohol Liaison Team have agreed a joint protocol to contact the designated Addaction Recovery Coordinator for the islands to facilitate a referral for anyone admitted who is not engaged in community treatment, into treatment, once discharged. 4. Multi-agency professionals meetings will identify individuals to assertively engage in treatment and support that engagement 5. The GPs serving the IOS are trained to offer the full spectrum of primary care alcohol and drug treatments. 6. Pharmacy staff are trained to screen patients to identify risks to health through drinking. 7. A full package of training for all personnel serving the islands in screening for alcohol use and awareness will be offered again in April 2017. 8. Further steps will de identified through the review and needs assessment currently underway. 9. An IOS specific Needs Assessment and commissioning intentions for 20117-18 is in progress, due to complete by 31st March 2017 10.We will make a continuing investment in DAAT staff support for the islands, including representation on strategic groups such as the Community Safety Partnership. We have reviewed Addaction’s copy of their report to you on this matter and I confirm that I support the lessons learnt. I believe that these steps will address the issues highlighted within your report, but that there is still more work to do to raise awareness and improve services available to islanders, thereby preventing future deaths. We commit to keeping the situation and improvement plan under regular review through quarterly Contract Review meetings with Addaction and with the Isles of Scilly Council and stakeholders. If you require any further information, please do not hesitate to contact me. Yours sincerely Joint Commissioning Manager Mobile: Email:
The Health Centre King Edward Lane St Marys Isles of Scilly TR21 ONS 14" January 2017 Dear Dr Carlyon, Thank you for your report regarding the sad and untimely death of Robert Lloyd on the Isles of Scilly on the 30" July. In response to the regulation 28 report | hereby outline the actions we have undertaken as a practice to help to prevent such a death again. I met with iii of the Drug and Alcohol Action Team of Cornwall Council, on the 12" January to discuss future services and how we can work together to ensure services improve. We will shortly be having a new Addaction worker on the Islands who will visit every 2 weeks. This will be a vast improvement on the previous set-up, where often contact was by telephone or Skype. We will host his sessions here at the surgery to ensure that we improve multi-agency working. He will also be able to feed into our multi-disciplinary team meetings for clients as required. In addition to this, training for our two pharmacists has been undertaken, to try and identify those who are at risk of harm from excess alcohol consumption and we are carrying out an audit of those who are recorded on our General Practice notes as having an alcohol intake of greater than the recommended limits. This will assist us in targeting advice to those who most need it, with the aim of increasing referrals to Addaction. Both Angela and | sit on the Community Safety Partnership, so we will ensure that the subject of problem alcohol use is on the agenda. The main focus of the CSP this year is around domestic abuse, so enhanced alcohol services will sit well alongside this as a focus. We all recognise that services have fallen short of what is expected over the last few years, but | am confident that this case will prove to reinvigorate the local offer, and will make services safer in the future. If you need further information please do not hesitate to contact me. Yours sincerely ~ Pe rs E \ 4 - Z \ a Pe Lead GP Isles of Scilly Health Centre
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