Prevention of Future Deaths reports · 2016
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 report | 2 Dec 2016 |
|---|---|
| Reference | 2016-0428 |
| Deceased | Peter Usher |
| Coroner | Nadia Persaud |
| Coroner area | East London |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths · Suicide (from 2015) |
| Organisation named | North East London NHS Foundation Trust |
| 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 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, | ~
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.
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
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 te ABO, “br, S www.nelft.nhs.uk om wr) Aa H i Diverse °o > Chair: Jane Atkinson enters & re sae Chief Executive: John Brouder NeceT WS 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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