Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0008, written 6 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 | 6 Jan 2017 |
|---|---|
| Reference | 2017-0008 |
| Deceased | David Moran |
| Coroner | Nicholas Rheinberg |
| Coroner area | Cheshire |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. 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: The Chief Executive, 5 Boroughs Partnership NHS Foundation Trust, Hollins Park House, Hollins Lane, Winwick, Warrington, WA2 8WA 1 CORONER I am Nicholas Rheinberg senior coroner, for the coroner area of Cheshire 2 CORONER’S LEGAL POWERS I 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. 3 INVESTIGATION and INQUEST On 20th July 2016 an investigation was commenced into the death of David Moran aged 49. The investigation concluded at the end of the inquest on 4th January 2017. The conclusion of the inquest was that the deceased who died as a result of a metformin overdose took a fatal overdose of his medication but that his intention in doing so could not be determined. 4 CIRCUMSTANCES OF THE DEATH The deceased who suffered from bi-polar affective disorder had a history which included suicide attempt and suicidal ideation. During a period of relapse he was contacted by a nurse from the Trust’s Warrington Assessment Team following a notification of concern from the deceased’s brother. The nurse attempted to complete the Trust’s screening tool without success. Trust Guidance set three levels of priority in dealing with referrals depending upon whether the need to see and assess the patient could be categorised as an emergency, as urgent or as routine. The nurse assessed the referral as routine. Subsequent to the nurse’s conversation with the deceased, his brother telephoned your service on not less than two subsequent occasions voicing increased concerns for the deceased but the calls were neither logged by the administrator who will have taken the call or entered within medical records with the result that an increasingly urgent need for assessment was not identified. 5 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) The Trust Guidance for categorising the urgency of a referral appeared imprecise. Further, in that the referral system will often depend on a telephone conversation only, there did not appear to be a default to urgent in a case where a screening assessment was not possible or in a case of doubt or ambiguity. (2) Communication between administrative staff and nursing / clinical staff did not appear to be effective. 1 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you and your organisation have 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 6th March 2017. I, 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 I have sent a copy of my report to the Chief Coroner and to the following Interested Person, Jeffrey Moran on behalf of the deceased’s family and the CQC.. I 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 6th January 2017 Nicholas, Leslie, Rheinberg Senior Coroner 2
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.
5 Boroughs Partnership NHS) NHS Foundation Trust Our Ref: IW/SB/deh Simon Barber Your Ref: INQ/16/629 Chief Executive Hollins Park Hollins Lane Winwick Warrington 13 February 2017 Cheshire WA2 8WA 46 FEB 2017 Tel: 01925 664001 H M Coroner Mr N L Rheinberg West Annexe Town Hall Warrington WA1 1UH Dear Mr Rheinberg Re: David Moran — deceased Thank you for your letter dated 6 January 2017 with regard to your findings into the death of Mr David Moran and the directions given under Regulation 28 and 29 of the coroner's (investigation) Regulations 2013. | would like to advise you of the actions the Trust has taken before the inquest and since receiving your letter. Taking the matters of concern raised in turn, | would like to advise you of the following: (1) The Trust Guidance for categorising the urgency of a referral appeared imprecise. Further, in that the referral system will often depend on a telephone conversation there did not appear to be a default to urgent in a case where a screening assessment was not possible or in a case of doubt or ambiguity. At the time of the incident the Trust guidance set three levels of priority in dealing with referrals, emergency, urgent and routine. The deceased’s referral priority was assessed to be routine. Unfortunately, information from Mr Moran’s family relating to concerns of a deterioration in Mr Moran’s presentation were not properly communicated or documented within the Assessment Team. Consequently, the increasing need for urgent assessment was not identified. A Better View... of mind & body e Chief Executive: Mr. Simon J. Barber 3 airman: Mr. Bernard Pilkington é é v7 Ch M d Pilkingt WSs SMOKEFREE Trust Headquarters, Hollins Park House, Hollins Lane, Winwick, Warrington, WA2 8WA Switchboard: 01925 664000 Since August 2016 a clinical project group has been developing a telephone triage system for the Assessment Team and this has been piloted in Warrington in December 2016. The project has been positively evaluated and Standard Operating Procedures developed to support the roll-out of this initiative. The Standard Operating Procedures provide clear guidance relating to the area of concern highlighted in part (1) of the Regulation 28. This means that all referrals where there is any element of uncertainty or where a person will not engage in the telephone triage, the default position will be to arrange an urgent face to face assessment within 72 hours of referral. Additionally, the Trust electronic patient recording system, RiO, is in use by all clinical and administrative staff which allows the tracking of progression of a patient’s referral. Additionally, the system enables staff to view information with regard to any changes in referral priorities. The Standard Operating Procedure went ‘live’ within Warrington Assessment Team as of 6 February 2017 and will be ‘live’ Trust-wide by 1 April 2017. (2) Communication between administrative staff and nursing / clinical staff did not appear to be effective. The work of the Assessment Team can be unpredictable due to the unplanned nature of referrals. | can confirm that at the time of the incident, the communication between administrative, nursing and clinical staff did not meet the standard we would expect. As a result of this, the Team Manager and senior operational managers have taken the following actions. e The Team has been briefed that all information relating to a patient and their referral must be documented within the electronic patient recording system RiO contemporaneously. e Information on RiO is available to all staff 24 hours a day. The Assessment Team now has a robust system in place whereby a senior clinical member of staff reviews all referrals on a daily basis and this information is relayed into the teams daily recorded morning meeting in which referrals are identified and actions and responsibilities for all staff are delegated. e Training in the form of lessons learned took place with the team through January 2016 and included an update of guidance and systems currently in place. If | can be of any further assistance or you require further information about the steps we have taken, please do not hesitate to contact me Yours sincerely Sealy Mr Simon J Barber Chief Executive A Better View... of mind & body ws Chief Executive: Mr. Simon J. Barber Chairman: Mr. Bernard Pilkington SMOKEFREE Trust Headquarters, Hollins Park House, Hollins Lane, Winwick, Warrington, WA2 8WA Switchboard: 01925 664000
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