Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0433, written 5 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 | 5 Dec 2016 |
|---|---|
| Reference | 2016-0433 |
| Deceased | Christopher Brennan |
| Coroner | Selena Lynch |
| Coroner area | South London |
| Category | Child Death (from 2015) · Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Oxleas NHS Foundation Trust · South London and Maudsley NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
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.
In the South London Coroner’s Court Inquest touching the death of Christopher Brennan Report to Prevent Future Deaths (Coroners (investigations) Regulation 28) THIS REPORT IS BEING SENT TO: 1. Resuscitation Council (UK) 2. South London and Maudsley NHS Foundation Trust CORONER | am Selena Lynch senior coroner for the coroner area of South London 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 On 2™ September 2014 | commenced an investigation into the death of Christopher Brennan, age 15. The investigation concluded at the end of the inquest on a1" September 2016. The conclusion of the inquest was that Christopher died from asphyxia due to acute upper airway obstruction. The circumstances in which he came by his death were recorded by the jury in a narrative form, as follows: Christopher suffered from mental illness and was a patient at Bethlem Adolescent Unit at the Bethlem Royal Hospital, Beckenham. He had a history of hearing voices, suicidal ideas, and self harm, usually by swallowing objects. On 31% August 2014 at about 8 pm, Christopher went to the communal toilet on the unit and obstructed his airway by swallowing the lid of a roll on deodorant wrapped in tissue paper. He called for help but suffered a cardiac arrest before the obstruction could be removed, and could not be resuscitated. | Christopher's actions were in part because of cumulative and continuing failures in risk assessment and management. His death was contributed to by neglect. CIRCUMSTANCES OF THE DEATH Please see the narrative conclusion set out in paragraph 3, above 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) In respect of the in-patient management: that there was no separate policy or guidance, other than a pictorial wall chart, regarding the assessment and management of risks posed by items that might be used to cause self harm. The complexities of managing these risks on an adolescent in-patient psychiatric unit were not therefore adequately considered, and this led to a lack of clarity and consistency. (2 LS With regard to resuscitation: the emergency equipment on the unit did not include a laryngoscope. The item obstructing Christopher's airway was subsequently used by ambulance personnel using Magill forceps with a laryngoscope, and this combination had been successfully used on a previous occasion when Christopher had swallowed a bottle top. Laryngoscopes are not part of the standardised items on the unit, and are not included in the Resuscitation Council guidance for mental healthcare settings. It has. been suggested that this is because they are complex devices that require intense training and competency assessments before staff can use them, and that it may be counterproductive to make them available. However, in view of the circumstances of Christopher's death, and the apparent prevalence of self harm in adolescent units, the matter is reported for consideration, both in relation to the laryngoscope itself and the access to staff trained in its use. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you and/or your organisations 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 1 February 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 Interested Persons: the family of Christopher Brennan, and Oxleas NHS Foundation Trust; and to the local Safeguarding Children Board. | 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. ~My Couaa pate 5 “Decent signep By coroner SUCH ke on ’ hia
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