Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0003, written 13 Jan 2017. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 13 Jan 2017 |
|---|---|
| Reference | 2017-0003 |
| Deceased | Natalie Gray |
| Coroner | Patricia Harding |
| Coroner area | Mid Kent and Medway |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
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 (1) 1 ;2 3 “4 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS | THIS REPORT IS BEING SENT TO: 1. Kent & Medway NHS & Social Care Partnership Trust ‘CORONER Oo Sc | | am Patricia Harding, senior coroner, for the coroner area of Mid Kent & Medway Lammers LEGAL POWERS OO | 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 27" April 2015 | commenced an investigation into the death of Natalie Gray,24 years. The investigation concluded at the end of the inquest on 1 November 2016. The conclusion of the inquest was suicide contributed to by neglect where there were gross | failures resulting from: 1.Insufficient risk assessments on 17", 20" and 21% April 2015 to highlight the risk of self harm 2. Inadequate MDT and nursing handovers on 21™ April 2015 including omission of the requirement to reassess Natalie's informal status should her presentation change or should she attempt to self discharge 3. Failure to convey and enforce the correct procedures for informal patient leave to OT support workers . 4. Failure by OT support workers to follow the leave procedure The following failures were found to have possibly contributed to the death: 1. A delay by staff at Priority House on confirming that it was Natalie who left Priority House and commencing a search 2. An unnecessary delay in the deputy ward manager reporting that Natalie was missing to Kent Police 3. A failure by the deputy ward manager to provide Kent Police with relevant information 4. A failure by the deputy ward manager to follow Trust policy by not contacting Natalie's next of kin The following matters were found to be relevant to the circumstances of the death; 1. A failure by the Mental Health Trust to record third party information on 17" and 21% April 2015 2. By a majority of 9:2 a failure by the call taker and back up dispatch officer to elicit relevant information from the informant | CIRCUMSTANCES OF THE DEATH Natalie Gray was 24 years of age at the time of her death. On 21 April 2015 she left Priority House where she was an informal patient and made her way to Barming railway station where she remained on the station platform for two hours until a non-stopping train approached at which point she jumped in front of it causing multiple injuries from which she died. Natalie was diagnosed with an emotionally unstable personality disorder and had a number of previous admissions to mental health hospitals following attempts to take her life. Although her mental illness was longstanding, in 2015 Natalie's father was gravely ill, her daughter was removed from her care as Natalie was subject of a police investigation and her relationship with her partner with whom her daughter was living, _| ended. These individuals were all major protective features in Natalie's life. Natalie had CORONER’S CONCERNS attempted to kill herself within a very short period of being discharged or self-discharging from hospital during the course of these events. On 9 April 2015 she was admitted as an informal patient to Priority House after attempting to gas herself. On 15 April 2015 she attended the funeral of her father and the following day was repeatedly heard to express quasi-psychotic thoughts and statements that she wanted to end her life. On 17 April 2015 she left the facility and travelled to Maidstone Hospital where she expressed the same thoughts to a hospital chaplain. The chaplain reported the visit to staff at Priority House who failed to record the matter. Natalie was seen on a ward round after retuming to the facility at which time she was told that her discharge was being planned. Although Natalie acknowledged that she had a good relationship with her care coordinator and was willing to engage with psychological therapy which had been planned for her some months before and was awaiting funding, it was evident that she was distressed about the proposed discharge and felt let down. She continued to express quasi psychotic thoughts. On the evening of 20 April 2015 Natalie was found to be very agitated and demanded to see a doctor as she wanted to discharge herself having learned that her discharge was imminent. She told a psychiatrist that she wanted to leave before she was kicked out, that she felt abandoned as a result of her daughter being taken away from her, her partner not wanting to know and her father having died, she was a burden and couldn't see a way forward but wanted to go home to die. As with previous occasions Natalie gradually calmed down. The psychiatrist recorded that Natalie's informal status should be reassessed if she further became agitated and wanted to leave the facility. A short while later Natalie became agitated again asking to leave and stating she didn’t want to live anymore. On this occasion she accepted medication and her observations were increased. She appeared settled throughout the night and the following morning. Shortly after 15.00 on 21st of April 2015 Natalie was heard to be shouting and | screaming in the ward corridor. She could not get into her room and was punching and kicking the door. After being let into her room by a nurse Natalie continued to be agitated. It was established that she wanted to speak to social services to arrange contact with her daughter. She eventually calmed down after the nurse spent some 20 minutes talking to her. Natalie's aunt had telephoned the facility around this time as she was concerned for Natalie following a communication from her the previous evening. She was told that | Natalie was fine. The telephone contact was not recorded The nurse returned to her office leaving Natalie in her room and some 10 to 15 minutes later saw an OT support worker letting Natalie off the ward. it was another 5 to 8 minutes before the nurse went to make enquiries with the OT support worker as she was on the telephone with the relatives of another patient. The OT support worker was not aware that an informal patient had to be signed out by a nurse. It had become common practice for OT support workers to let informal patients off the ward to smoke in contravention of Trust policy. As a result of insufficient and inaccurately recorded risk assessments and inadequate | nursing and MDT handovers none of the staff working on 21 April 2015 save the deputy ward manager were aware that Natalie was a medium risk of self-harm which became high if she left the ward, nor were they aware that her informal status should have been reassessed in the circumstances under which she left the hospital. Once it had been established that it was Natalie who left the facility a local search was conducted by two members of staff but that Natalie was missing was not reported to the police for some 30 to 40 minutes. When the police were contacted by the deputy ward manager he did not adequately convey relevant information about Natalie or her risk of self-harm andthe call takers from Kent Police did not seek to elicit relevant information which would have assisted in the classification of the call and the police response. During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the | circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. — Whilst it is recognised that a significant number of changes have been made by both the Mental Health Trust and Kent Police to procedures and protocols that were in place at the time of the death of Natalie Gray, a number of matters remain outstanding, are subject of continuing work or require clarification and as a result the following matters are of concern: (1) The approach to discharge planning has been addressed on a general basis but the pathway for those with a diagnosis of personality disorder is currently under review and has not been finalised. it remains a concern that a patient with an emotionally unstable personality disorder will meet the current criteria for discharge but shortly thereafter be at risk particularly where specialist therapies are planned but have not been approved/started (2) The risk assessment form has not yet been addressed and is under review, there remains an issue as to whether the risk is recorded as a present risk alone or includes chronic risk (particularly for those with personality disorders) as oppose to historic risk. Although risk is discussed at handovers and ward rounds there is no evidence that the risk rating is communicated or signed off by the doctor when the record is completed by a nurse/junior doctor (3) Kent Police and Kent & Medway NHS & Social Care Partnership Trust have agreed a Missing Person Procedure implemented 1" December 2015. There is a concern about the terminology for use in the risk assessment that the Mental Health Trust is required to complete which may lead to an inaccurate risk assessments. There appears to be no explanation as to whether the risk is that formally documented or the risk at the time the patient left the facility which may be less clear. Additionally the use of the term ‘significant’ is highly subjective, is it intended to mean a likely risk of self harm or something more. It is not clear how the Trust should deal with those likely to place themselves in danger and therefore at medium risk of self harm, in terms of the timescales involved and whether 999 should be used or not. By way of example, Natalie’s documented risk was inaccurately recorded as low, when it should have been medium and on leaving the facility medium to high, this could lead to an underestimation of the risk of self harm depending on how the form is interpreted by staff. (4) Significant information from third parties was not recorded in the Rio notes when received or at all 6 | ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | 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 14" March 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. 8 | COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the following Interested Persons Kent & Medway NHS & Social Care Partnership Trust, Kent Police, |__| [II have also sent it to Care Quality Commission and NHS England 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. "9 | [DATE] 13" January 2017 [SIGNED BY CORONER] Ftd,
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.
Patricia Harding
H M Senior Coroner for Mid Kent
and Medway
Archbishops Palace
Maidstone
Kent
Your reference
My reference HG/366
Date 14 March 2017
Dear Madam
Trust Headquarters
Farm Villa
Hermitage Lane
Maidstone
Kent
ME16 9PH
Tel: 01622 724137
Fax: 01622 724165
Website: www.kmpt.nhs.uk
Re: Preventing Future Death; The Inquest in to Natalie Gray’s death Response
I joined Kent and Medway NHS and Social Care Partnership Trust (the Trust) in June 2016.
Soon after joining I was made aware of the tragic circumstances surrounding Natalie’s death
on 21st April 2015. I received regular updates in relation to the inquest which concluded on
1st November 2016. Following its conclusion
(Acute Service Line
Director), who attended the entirety of the inquest, briefed myself and the Board on the
inquest’s findings.
I have carefully considered the three areas you have highlighted as being of particular
concern. My response is set out against each of your points.
1. The approach to discharge planning has been addressed on a general basis but
the pathway for those with a diagnosis of personality disorder is currently under
review and has not been finalised. It remains a concern that a patient with an
emotionally unstable personality disorder will meet the current criteria for
discharge but shortly thereafter be at risk particularly where specialist therapies
are planned but have not been approved/started.
My response in relation to this is twofold. It consists of steps already put in place to
support discharge from in-patient services including those with a diagnosis of
Personality Disorder in line with NICE guidance. The second part, outlining our longer
term plans as part of the ongoing Personality Disorder Review being over seen by our
Executive Medical Director.
Dealing with the former first, the countdown to discharge tool about which I understand
you received oral evidence on during the course of the inquest is key to this. In
addition to this, links between Community Mental Health teams (CMHT) and the Crisis
Resolution Home Treatment (CRHT) team have been strengthened. A daily Crisis Call
(Monday to Friday) has been implemented Trust-wide. This allows for a patient
focused discussion to occur and for the CMHT to be fully involved in any decision to
discharge a patient from either a ward or the CRHT.
Chairman – Andrew Ling
Chief Executive – Helen Greatorex
The Trust Patient Flow Board provides a further means by which services can closely
monitor the input that service users have, by ensuring that once admitted to the
inpatient setting a care coordinator is allocated through the process of patient flow
meetings, using the Board as a guide and reference point.
The Medical Psychotherapist and Lead Consultant for Personality Disorder unit is
providing specialist advice and training to the acute wards on the management and
discharge planning for their patients with Personality Disorders. In February 2017, he
started training staff at Priority House on a ward by ward basis. This includes risk
management formulation and mindfulness. By the end of April all staff at Priority
House should have received this training. This will then be rolled out Trust-wide across
the Acute Service Line.
A Trust-wide Personality Disorder Panel is being established. Complex and high risk
patients will be discussed and support provided to access appropriate interventions.
The Panel will consist of a Consultant Medical Psychotherapist/Psychiatrist, Director of
Specialist Services, Assistant Director of Acute Service Line, Clinical Lead for
specialist psychological practice and Clinical Lead for Community and Recovery
services.
The first meeting to establish the panel and approve terms of reference is on 1st May
2017. It is proposed it will meet every two weeks. The Panel will initially focus on our
top 50 frequent attenders of acute services to provide support and offer guidance to
Care Coordinators in managing these complex cases and assisting with access to the
appropriate specialist psychological interventions.
The Trust’s Personality Disorder review concludes in May. The issue of safe transition
between acute and community services is a central part of this review. A key aim is for
all appropriate patients to be able to access specialist psychological therapies. The
Trust Board will be presented with plans for a new integrated care pathway for
Personality Disorder to consider at the end of May.
As part of the development of the new Personality Disorder pathway we have been
considering the stepdown from the acute pathway and into the community and support
that is available to patients including psycho-educational groups, service user network
support groups which may be provided by voluntary organisations and specialised
therapy appropriate for the patients needs, additional training for Care Coordinators
and approved care planning for newly admitted Personality Disorder patients.
It is a key component of our suicide prevention strategy (launched in September 2016)
and sets out the Trust’s strategy over a three year period.
The strategy recognised that those with a diagnosed Personality Disorder are at a
higher risk, and therefore require priority due to being in this high risk group. There is
work underway in line with this to transform clinical risk assessment and management,
both in practice and recording, with new training in place, and new risk assessment
documentation about to come onto our electronic clinical record system for general
2
use. As an organisation we are committing ourselves to achieve greater engagement
of patients, families and carers and work jointly with them to achieve effective “safety
planning”.
.
2. The risk assessment form has not yet been addressed and is under review, there
remains an issue as to whether the risk is recorded as a present risk alone or
includes chronic risk (particularly for those with personality disorders) as
oppose to historic risk. Although risk is discussed at handover and ward rounds
there is no evidence that the risk rating is communicated or signed off by the
doctor when the record is completed by a nurse/junior doctor.
In January 2017 the Trust launched a newly reviewed risk policy and risk summary
form, this is currently being implemented Trust-wide.
We have taken a number of steps to highlight how the points of transition of care are
an area of risk for those with a diagnosis of Personality Disorder. Changes have been
made to our Clinical Risk Policy to reflect this. There is a flow diagram in the policy
providing guidance on when to assess and reassess clinical risk and it highlights
transition periods.
I am aware that its development was informed by learning from Serious Incidents and
near misses. Natalie’s was a case where the grading of risk was key as there was
always a chronic risk which would fluctuate. Updated mandatory training focuses on
the critically high risk period as well as other transitions in care. The updated training
explains how the period is often referred to as the ‘Low Risk Paradox’ with risk
assessed as low in one environment yet high or escalating in another
We are using learning from real case examples with our clinicians to ensure that the
multidisciplinary teams understand risk, its importance and variability in a more
sophisticated sense.
We have changed our approach to testing practice in relation to risk assessment. As
part of the programme for implementation of the new Risk Summary, auditing is
focused on quality of the risk assessment rather than just the percentage of risk
assessments completed.
We recognise the importance of the communication of risk both between members of
the multidisciplinary team and from shift to shift and this is recognised in training.
The importance of clearly recording the Consultant’s review of risk has been discussed
and action taken to ensure this happens. Changes are being made to our electronic
patient record to make it easier to record and review.
Shift patterns and handovers are being reviewed so that they can be structured in such
a way as to ensure that the key information is passed onto the next shift. We are
considering standardising shift times across all sites and wards and to cost this
accordingly. This would be with a view to an extended handover time.
3
3. Kent Police and Kent & Medway NHS Social Care Partnership Trust have
agreed a Missing person Procedure implemented 1st December 2015. There is a
concern about the terminology for use in the risk assessment that the Mental
Health Trust is required to complete which may lead to an inaccurate risk
assessments. There appears to be no explanation as to weather the risk is that
formally documented or the risk at the time the 'significant' is highly subjective,
is it intended to mean a likely risk of self harm or something more. It is not clear
how the Trust should deal with those likely to place themselves in danger and
therefore at medium risk of self harm, in terms of the timescales involved and
whether 999 should be used or not. By way of example, Natalie's documented
risk was inaccurately recorded as low, when it should have been medium and on
leaving the facility medium to high, this could lead to an underestimation of the
risk of self harm depending on how the form is interpreted by staff.
We have taken a series of steps to resolve this. They include
• Jointly agreed Adverse Incident Process shared by Kent Police and the Trust.
• A compliance bulletin and reminders across the whole Trust, specifying terminology
to be used.
• From April 2017 there will be a third specifically designated Police Officer to the
acute service line, these are already in situ in North and East and from April this will
extend to West Kent, this Officer will be based at Priority House. This supports
improvements to communications, joint working, joint learning, and ultimately
reduction in risk of harm.
• We continue to work closely with Kent Police on a number of joint projects,
including Operation Sotor which has been recognised as an item of good practice
nationally.
• Since September 2016 the Trust has established a KMPT and Kent Police
Executive Liaison Meeting which takes place quarterly and is attended by KMPT
CEO, Exec Lead, Assistant Chief Constable and Strategic Lead Superintendent
from Kent Police, Kent Police and Crime Commissioner and the Accountable
Officer from West Kent CCG. This is an executive steering group for joint strategic
planning and to support the delivery of Crisis Care Concordat. Building on the
positive relationships with Kent Police is helping identify and address similar risk to
those found in Natalie’s case.
As I conclude this letter, I am struck by how much has or is changing since the tragedy
of Natalie’s death. As Chief Executive I take full and personal responsibility to make
sure that we are doing everything we possibly can to avoid such a tragedy being
repeated. I offer you as H. M. Senior Coroner my assurance that I believe we are
addressing the serious concerns that you raise. I recognise that we have a significant
amount of work to do in order to create truly patient focused, high quality services.
4
I would with your agreement, like to provide you with a further update in the autumn.
By then, I believe our service for people with Natalie’s diagnosis will be transformed.
Yours sincerely,
Helen Greatorex
Chief Executive
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