Prevention of Future Deaths reports · 2016

Peter Usher

Regulation 28 report to prevent future deaths, reference 2016-0428, written 2 Dec 2016. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report2 Dec 2016
Reference2016-0428
DeceasedPeter Usher
CoronerNadia Persaud
Coroner areaEast London
CategoryHospital Death (Clinical Procedures and medical management) related deaths · Suicide (from 2015)
Organisation namedNorth East London NHS Foundation Trust
Sourcejudiciary.uk record · original PDF
Responses published2

The report

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 IS BEING SENT TO:

1. John Brouder, Chief Executive, North East London Foundation NHS Trust,
Goodmayes Hospital, Barley Lane, Goodmayes, Ilford, Essex, IG3 8XJ

1 | CORONER

| am Nadia Persaud, Senior Coroner for the Coroner area of East London

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.
http://www. legislation.gov.uk/uksi/2013/1629/part/7/made

3 | INVESTIGATION and INQUEST

On the 27" January 2016 | commenced an investigation into the death of Peter Daniel
Usher. The investigation concluded at the end of the Inquest on the 29" November
2016. The conclusion of the Inquest was a narrative conclusion:

Mr Usher took his own life. This was in part because the risk of his doing so was not
fully and carefully assessed and appropriate precautions were not taken to prevent him
doing so.

4 | CIRCUMSTANCES OF THE DEATH

Mr Usher was a 39 year old gentleman. From January 2015 he had presented to his GP
on a number of occasions complaining of symptoms of depression. In the very early
hours of the 28"" December 2015, Mr Usher sent a text to his brother which indicated
possible suicidal intentions. At around 01:37 he was seen entering the grounds of the
Bower Park Academy school. Police were called and found him with a deliberately
sharpened twig held to his neck. Mr Usher also climbed up a tree in the presence of the
police officers. They noted that a laptop and a belt were already in the tree. The belt
was tied to a branch of the tree and in the presence of the officers Mr Usher tied the
other end of the belt around his neck and threatened to jump. Mr Usher explained that
he had just received some upsetting news about his relationship. He also admitted to
drinking whiskey and taking cocaine that evening. The officers were able to talk Mr
Usher down and he had to be tasered for his own safety. He was detained by the police
under Section 136 of the Mental Health Act and taken into the Section 136 suite at
Goodmayes Hospital. Mr Usher was taken to hospital at 02:56. The duty doctor and
ACAT member were informed. The ACAT member set about checking records for prior
psychiatric contact. Information was gathered from a previous attendance within
another Trust under Section 136 in February 2015. A section 136 assessment took
place by a junior doctor and the duty nursing officer. A decision was made to discharge
Mr Usher from Section 136 at 04:50. He left the hospital at 05:00 on the 28" December
2015. From the evidence available at the Inquest it is likely that Mr Usher returned to
the Bower Park Academy School on the 29" December 2015 and hung himself froma
branch of a tree in the school grounds. His body was not located until the 21°" January _|

2016.

CORONER’S CONCERNS

The MATTERS OF CONCERN are as follows. —

1. The assessing team did not carry out a detailed assessment of Mr Usher, to
include not only a personal assessment but also to obtain relevant clinical
information from both professional and non-professional sources. This would
have included information from the family and GP. There was also relevant
information available to the paramedics and police that was not elicited by the
assessing team.

2. The Trust policy requires that the assessment should be carried out by the duty
doctor and member of the Home Treatment Team. The policy also requires that
the doctor must inform the on-call doctor of the arrival and discuss the outcome
of the assessment with them. The Home Treatment Team member was not
present during the course of the assessment. He was gathering relevant clinical
information from a previous Section 136 attendance. The information appears
to have been requested shortly after 03:00’ and not received until around 04:47.
This was partly due to safe haven procedures which had to be complied with,
before a fax could be sent. The Home Treatment team member attended as the
assessment was wrapping up. The on-call doctor was not informed of Mr Usher.

3. The Trust policy requires that an AMHP (Approved Mental Health Professional)
be notified of the planned assessment. This also did not take place.

4. The police had received contact from family members whilst they were present

at the hospital, confirming the concerns of family members due to the text
received. This was not passed on to the hospital staff. It became apparent
during the course of the Inquest that the police also had access to information
which was relevant to the circumstances of the preceding events which would
have been relevant to the mental state of the deceased. It would appear that
inadequate questions were asked by the receiving hospital team in relation to
the circumstances leading to admission.

5. The junior doctor gave evidence to confirm that he was the only doctor available
for 11 wards and 200 patients. It would appear from information provided by the
Trust, that the number of Section 136 assessments is increasing substantially
and therefore there is a concern in relation to adequate medical staffing.

6. The evidence during the course of the Inquest and the evidence received from
the independent psychiatrist raised a number of concerns in relation to the
quality of the overall assessment and risk assessment carried out by the duty
doctor. No issues relating to the medical input were identified in the Trust's own
Root Cause Analysis. Further concern was raised during the course of the
Inquest by the apparent lack of insight by the duty doctor and by the apparent
inability to reflect on practice.

7. Itis unclear from the evidence heard during the course of the Inquest whether
there is any audit of clinical decision making during Section 136 assessments.

8. The Section 136 policy contains a 6 hour target for assessments to be
completed. Section 136 itself, allows a period of up to 72 hours. It is unclear
from the evidence as to whether the 6 hour limit places undue pressure upon
staff to carry out assessments without gathering all of the available relevant
evidence.

9. There were inefficiencies in practice which resulted in the member of the Home
Treatment Team missing the 136 assessment. He had to wait for approximately
4 hour 45 minutes for clinical information to be provided. He had to go through
Safe Haven procedures and to wait for a fax. An email to a secure email
address may have avoided these delays.

ACTION SHOULD BE TAKEN

In my opinion action should be taken to prevent future deaths and | 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 27'" 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 me
(representative for the family). | am also forwarding a copy to the Care Qualit
Commission, Borough Commander REEMMMIPS) and a
(Director of Public Health).

| 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.

02/12/2016 [SIGNED BY CORONER] cK, | ~

Responses

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.

Response from Borough Mental Team (PDF)
This report has been compiled in response to the Regulation 28 Report to Prevent Future
Deaths issued by the Senior Coroner for the Coroner area of East London Mrs Naida
Pesraud.

A number of points were highlighted by Mrs Persuad when looking into the tragic
circumstances leading to the death of Mr Usher. Whilst the Metropolitan Police were only
mentioned briefly during point 5.4, which highlighted a distinct lack of communication given
the circumstances between the police officers and staff from Goodmayes Hospital, It was
considered appropriate to. conduct an internal review of the way Havering Borough deal with
incidents involving Mental Health.

Through this investigation four key areas were identified for improvement
1. Handover of patients between the police and 136 suite staff
2. Filing and Storage of 136 paperwork
3. Supporting officers dealing with 136 incidents
4

. Training

1. Handovers

1.1 — The $136 paperwork completed by officers on the street is Form 434. The
form has two particular areas that by their description can create ambiguity when
completing them. The first is towards the top where it has the words
“Friends/Family” and a space adjacent to it for the officer to fill out. | believe this
needs to be more specific and should be changed to “Next of Kin.” This will give the
officers more clarity when completing the form and eliminating the potential risk of
important information being missed. The second is further down and reads “Name
of person handing over too” then as above there is a space adjacent for the officer
to complete. This leaves some doubt as to whether the person accepting
responsibility needs to sign. Under the s136 Pathway it clearly states that a
signature is required. However this is not always done leaving both Goodmayes and
the Police open to criticism. By reducing the section mentioned above and adding a
“signature” box this legal requirement would be complied with. These adaptions
would have to be passed through the Metropolitan Police for approval. However this
process is invariably lengthy, there is additionally the consideration that the MPS,
will be moving to digital paperwork, as such it is unknown whether the proposal will
be accepted.

1.2 - In the interim period we have been working closely with North East London
Foundation Trust (NELFT) and are in the process of designing a bespoke handover
form to be held at the 136 suite. The theory behind this is to create a document that
is specifically designed to identify information needed about the patient from the
police to enable Goodmayes staff to provide the most appropriate care for the
detained person.

2. Filing and storage of 136 Paperwork

2.1 - Traditionally all 136 paperwork would be completed and retained securely for a
period between 7-10 years. This causes us with difficulties should the information
from the original copy need to be viewed remotely. In addition when someone is
detained under s136 an intelligence report would be created but wouldn't always

provide the full details of what was recorded on the 136 but more of the
circumstances of how police came to be in contact with the patient. This resulted in
information from the form 434 being missed. To rectify this, a new system has been
implemented whereby all paperwork is scanned and attached to the intelligence
report. The digital paperwork is then stored on an internal server. This is important
should we have occasion to deal with a repeat patient as it will enable us to gain a
more accurate intelligence background to the individual.

2.2 - The form 434 once completed now has an index able system requiring the
completing officer to obtain a reference number which is cross referenced between
the intelligence report and the adult come to notice (ACN) report. These are filed in
monthly sections both digitally and physically enabling easier access.

3. Supporting officers dealing s136 incidents

3.1 - Since the introduction of the s136 Pathway in late 2016 there is now guidance
and clarity around who takes what responsibility and when. A streamlined flowchart
has been created giving the officers on the street a clear understanding of what is
expected of them, the LAS and Goodmayes staff. This has been cross referenced
with the s136 Pathway to dispel any myth or hearsay over roles and responsibilities.
NELFT have viewed the document and are proposing to hold a copy within the
reception area of the 136 suite. This has been sent to the Metropolitan Police
Territorial Policing (TP) Mental Health team as a proposal to be send out across all
boroughs within the London.

4. Training

4.1 - Giving officers on the street the correct training and development is paramount
to providing the highest levels of service to the public. It is important to appreciate
that police officers are not mental health experts. However it is important for them to
have a better understanding of what signs and symptoms correlate to what illness
and how patients may behave if they have a particular illness. After liaising with
NELFT they have agreed to provide training in three areas:

a) Signs and symptoms of common mental health concerns
b) NHS departments that may be able to assist as an alternative to 136
c) Police Officers own mental wellbeing

4.2 - Mrs Persaud herself has very kindly agreed to provide a video presentation
giving an insight into s136, Coroners Court, what is a regulation 28 notice and the
role of a coroner.

4.3 - We are currently in discussions with ho specialises in
inquiries and claims against the police. If agreed, this will give the officers a different
perspective of how they deal with mental health.

Time Scales

1.1 - There is no realistic time scale that can be attributed to this point. The Metropolitan
Police are trying to move to digital policing by 2020. This report has been directed to our
policy unit, Central Mental Health Team and Legal department for consideration. NELFT are
also going to petition for the form to be changed.

1.2 - There is a review meeting planned for early February for a progress report. | am
confident that by the end of February to mid March this will be completed.

2.1 - This was implemented in November 2016
2.2 - This was implemented in January 2017

3.1 - A circulation email will be sent before the end of January. Copies of the 136 Pathway
along with the flowchart have been left in the supervisors office and within the GPC
(command unit consisting of Duty Inspector and Hot Sergeant amongst other assets) as
points of reference.

4.1 - With the amalgamation of Barking & Dagenham, Redbridge and Havering boroughs
training is currently undergoing vast transformation. At the moment the only estimated
timescale is the latter part of 2017 (August to December).

4.2 - Mrs Persaud has been kind enough to offer her time after July 2017 to produce the
video presentation.

4.3 - | am currently in the process of liaising with Mr Thomas regarding his participation in
the training package.

Mr Usher's death is one of tragic circumstances and the Metropolitan Police, in particular
Havering Borough offer our condolences and deepest sympathies to his family. We as an
organisation are dedicated to providing the highest levels of service to the public.

We hope that the procedures, training and enhanced working relationships that have been
developed due to this report will go some way to preventing any future deaths.

Respectfully submitted for your consideration

Police Sergeant

Borough Mental Health Liaison Officer
Response from Nelft NHS Trust (PDF)
Best care by the best people NELFT INHS|

NHS Foundation Trust

PRIVATE & CONFIDENTIAL Trust Head Office
Ms Nadia Persaud The West Wing
Senior Coroner CEME Centre
Walthamstow Coroners Court Marsh Way
Queens Road Rainham
Walthamstow RM13 8GQ

London E17 8QP

Tel: 0300 555 1298
e-mail: john.brouder@nelft.nhs.uk

24 January 2017

Dear Ms Persaud,

Re: Inquest touching upon the death of Mr Peter Usher

Response to Regulation 28 report

| refer to a Regulation 28 report dated 2"? December 2016.

The Trust is committed to continuously review its service for the purposes of improving quality of care and
patient safety and | am grateful for bringing these issues to my attention.

The Trust has given and continues to give the most serious consideration to the concerns regarding the care
provided to Mr Usher, which were highlighted in the Regulation 28 report.

Please find enclosed the Trust’s action plan to address the issues identified in Regulation 28 report.

Yours sincerely,

,

dla £ 4 we Le _

\
John Brouder
Chief Executive

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Chief Executive: John Brouder

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NHS Foundation Trust

Action plan to address the concerns identified at the Regulation 28 report
following the Inquest touching upon the death of Mr Peter Usher

No of
concern
in reg. 28
report

Deadline for
completion

Action owner

To send out a ‘Freedom of Information’ (FOI) request | RK/VP 15.02.2017

to other mental health trusts in the Greater London
RK/VP 31.03.2017

area, to establish how other trusts are handling the
pressures associated with the requirements set out
Page 1 of 4

1. $136 MHA (VP and RK)

2. Par 16.46 of MHA Code of Conduct (VP and
RK)

3. Par 14.71 of MHA Code of Conduct (VP and
RK)

The findings of the FOI request will then be
considered during the review and update of the
Trust’s policies and procedures in relation to $136
assessments.

With emphasis on the requirement to comply with:

e Par 14.71 MHA Code of Practice that all
available, relevant clinical information,
including that in the possession of others,
professional and non-professional” (e.g.
obtained from the family, GP, police,
paramedics etc as reasonably practicable);

¢ $136 of the MHA 1983 that the patient
should be examined by a registered medical
practitioner and interviewed by an approved
mental health professional; and

e Par 16.46 of the MHA, Code of Practice, that
the doctors examining patients should
wherever possible, be approved under
section 12 of the Act; and where the
examination has to be conducted by a doctor
who is not approved under section 12, the
doctor concerned should record the reasons
for that.

e The GMC and the NMC requirement to keep
comprehensive and contemporaneous
records to evidence compliance with the
above listed requirements.

Taking into consideration the information received
from the FOI request (as mentioned above) to review
and update:

1. $136 questionnaire upon arrival of the
patient at the s136 suite (which the staff
have to complete) (RK)

2. §136 handover form (also known as 434

form) (which the Police should complete)

(RK)

$136 policy (RK)

$136 guidance (VP)

5. Weekly s136 internal audit tool development

(RK)

Bw

NELFT is currently in the process of reviewing the 28.04.2017
workload of the Goodmayes on call doctors. We aim
to implement changes by beginning of February. An
audit on junior doctor on call workload will be
undertaken at the beginning of March 2017 to see if
the changes have had an impact on their workload,
and what other measures can be put in place to
reduce the pressure associated with the workload,

when completing s136 assessments.

In February 2017 new junior doctor contracts are
coming into force. As part of the new contract, junior
doctors will be able to raise exception reports if they
have concerns regarding their workload.

The exception report will be subjected to a formal
review process. The Guardian of Safe working will be
involved to ensure safe working practices.(VP)

To introduce and carry out a random regular clinical 28.04.2017
decision making audit for $136 suite, to monitor the
quality of the overall assessments as well as the risk

assessments. (RD)

To address the lack of insight and potential lack of 30.06.2017
ability to reflect on practice, the relevant doctor has

been asked to self- refer to the GMC.

In addition to this the doctor was asked to undertake
a formal ‘360 degree’ feedback from the colleagues
and the patients in order to appropriately reflect

Page 2 of 4

upon his practice and professionalism. (VP)

To address the concern that the RCA investigation did | BM/ VP/GG 28.04.2017
not identify the issues regarding medical input:

a reflective session will be arranged between
Investigating Officers and the Associate
Medical Directors to raise and discuss the
gaps in this investigation and awareness of
barriers to raise concerns re practice of
medical staff; (BM)

board workshop regarding the SI
investigations and the Coroner’s Inquests will
be held and one of the agenda items will be
to discuss the importance of the SI
investigation to appropriately identify and
raise the issues in care delivery for the
purposes of learning from serious
incidents;(BM and GG)

a possibility will be explored to invite the
Senior Coroner to attend the Trust and
deliver a presentation to the Directors who
are signing off the reports and the Serious
Incident investigators as well as other
personnel such as modern matrons on the
impact and importance of the thorough and
fearless Serious Incident investigation from
the perspective of the Jurisdiction of the
Coroner’s Inquests. (GG)

To review and update the s136 guidance and the 31.03.2017
$136 policy to ensure that the staff are:

encouraged to utilise the legal time limit to
the full extent, for detention of patients in
cases, where there is lack of collateral
information available at the time of the
assessment and more time is needed to
ensure that all sources of information are
exhausted to meet the requirement set out
in 14.71 MHA Code of Practice; (RK and VP)

not placed under undue pressure to carry out
assessments without gathering all of the
available relevant evidence. (RK and VP)

To create a generic and secure nhs.net account for OJ/VP/ RK 31.03.2017
$136 suite, which would be monitored and used by
the bleep holders to receive the collateral

Page 3 of 4

confidential information about the patients from
other sources in order to comply with the
requirement set out in the paragraph 14.71 MHA
Code of Practice.(OJ)

To review and update the s 136 guidance and the
$136 policy to ensure that the staff should be
encouraged to use the secure email as a preferred
means of communication for the purposes of
requesting and receiving the collateral information.
(RK and VP)

Page 4 of 4

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