Prevention of Future Deaths reports · 2017

Matthew Roberts

Regulation 28 report to prevent future deaths, reference 2017-0028, written 9 Feb 2017. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report9 Feb 2017
Reference2017-0028
DeceasedMatthew Roberts
CoronerBridget Dolan QC
Coroner areaWest Sussex
CategoryHospital Death (Clinical Procedures and medical management) related deaths
Organisation namedAvon and Wiltshire Mental Health Partnership NHS Trust · Sussex Partnership NHS Foundation Trust
Sourcejudiciary.uk record · original PDF
Responses published1

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

[—
THIS REPORT IS BEING SENT TO:

Mr Colm Donaghy, Chief Executive, Sussex Partnership NHS Foundation Trust .

i}

CORONER

1 am Bridget Dolan QC, assistant coroner, for the coroner area of West Sussex

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.

INVESTIGATION and INQUEST

On 7 April 2016 the Senior Coroner commenced an investigation into the death of Mr
Matthew Christopher Roberts. The investigation concluded at the end of the inquest I
held on 3 February 2017.

The conclusion of the inquest was that Mr Roberts died on 7 March 2016 from a
complication of necessaty medical treatment, the medical cause of his death being (1a)
major haemorrhage at tracheostomy site (1b) acute arteritis of the innominate artery (2)
coma and hypoglycaemia due to mixed drug and insulin toxicity.

4 | ORRNSTANGES OF THE DEATH

1. Mr Roberts, who was born on 28 December 1993, was a talented music student
studying at the University of Chichester. In late 2015 he suffered what appeared to
be a first episode of psychosis. This led to him taking an intentional overdose of
insulin in early December 2015. After a brief psychiatric hospital admission under
Sussex Partnership NHS Foundation Trust (SPFT) Mr Roberts was discharged to
his parents’ home in Wiltshire on 24 December 2015.

2. Mr Roberts was supervised and treated, initially, by the Avon and Wiltshire Mental
Health Partnership NHS Trust’s ‘North Wiltshire Intensive Service’ team and
subsequently by the Wiltshire Early Intervention in psychosis team (the EI team).
The transfer from the Sussex services to the Wiltshire services over the Christmas
period was described as “seamless”. Contact was made with him very shortly after
his return and throughout his period in Wiltshire Mr Roberts was seen or spoken to
by team members from the Avon and Wiltshire mental health services almost daily.

3. It was recognised that, in time, Mr Roberts would return to Chichester University in
the SPFT’s catchment area, and so on 22 January 2016 the Wiltshire EI team made
preliminary contact with the relevant Sussex EI team in Bognor who indicted they
would accept a referral.

10.

By 12 February 2016 there had been a noticeable improvement in Mr Roberts’
mental state and in view of the perceived lowered risk of suicide the plan, formed in
liaison with the University mental health services, was that Mr Roberts would soon
return to Chichester and recommence his University studies.

It was recognised that this plan involved some therapeutic risk taking as his return
to University would, potentially, be a stressful event for Mr Roberts. A risk
management plan was therefore devised. It was determined that Mr Robert’s
mental state and risk of suicide was such that he would still require NHS
supervision alongside engagement with the University counselling service on his
return to Sussex. Indeed the Wiltshire EI team manager described the involvement
of the local Bognor EI team as a “crucial” aspect of the risk management plan.

Mr Roberts also recognised himself that he needed such support as on 12 February
2016 he asked for the Team which covered the Chichester area to be informed of
his impending return and for an appointment to be arranged for the Thursday or
Friday of the following week (i.e. 18/19 February)

On Tuesday 16 February 2016 the team manager of the Wiltshire EI team made a
telephone referral to the SPFT’ Bognor EI team when he spoke to the Bognor team
manager. He informed the Bognor EI team that Mr Roberts was returning to
Sussex the following day (although in the event he actually returned on Thursday 18
February).

The outcome of that telephone conversation was that the Wiltshire EI team
manager understood that Mr Roberts would be offered an appointment with the
Bognor EI team on Thursday 18 or Friday 19 February 2016. The Bognor EI team
manger did not, however, share this understanding. | The Bognor team manager
told the inquest that when he offered to arrange an appointment for Mr Roberts
“this week” he had meant that telephone contact would be made with Mr Roberts
within the next 7 days (as was the service standard) and then at that telephone
contact a future date for a face to face appointment would have been arranged with
Mr Roberts.

Following the telephone conversation between the two EI team managers some
supplementary information was faxed by the Wiltshire EI team manager to the
Bognor EI team. That fax was time stamped as arriving at Bognor at around 13.30
hours on Tuesday 16 February 2017. The fax included (amongst other documents):
correspondence from a Consultant Psychiatrist to the GP dated 21 January 2016
that set out the psychiatrist’s assessment of Mr Roberts’ current mental state,
progress in treatment and diagnostic formulation; a letter from the Wiltshire EI
team manager to the University counsellor, dated 12 February 2016, setting out the
perceived level of risk and containing the risk management plan; and a risk
assessment document. The cover page to the fax was clearly marked to show the
fax consisted of 22 pages.

The following day, on 17 February 2016 a daily ‘zoning meeting’ was held by the
Bognor EI team. At this meeting all new referrals would be allocated to team
members and the inquest was informed that there should then have been initial
consideration of the patient’s clinical needs and the level of risk the patient

presented to allow the team to formulate a plan and determine a response time for

14.

15.

16.

17.

making the first telephone contact with Mr Roberts.

. The evidence of the Bognor EI team manager (confirmed by his immediate line

manager) was that there was not always opportunity to read the information sent by
a referrer before such a zoning meeting, and so the practice within the team was to
read the referral information at a later time. At the latest this would be shortly
before the first face to face contact with the patient.

. Mr Roberts’ case was allocated to the Bognor EI team manager. However the team

manager had not read any of the faxed documents, therefore he relied solely upon
the verbal information provided by the referrer to determine the urgency with
which telephone contact should be made. The detailed written information sent by
the Wiltshire EI team was not considered by the Bognor EI team to inform the
decision-making regarding the patient’s needs and the current level of risk.

. Indeed, in Mr Roberts’ case the Bognor EI team manager had no recollection of

ever reading the faxed material and I concluded at the inquest that it was never read
by anyone associated with the Bognor team. On considering the fax actually
received, which was disclosed part way through the inquest, it was apparent that it
was incomplete — it was automatically stamped to show it as containing only 17
pages in total (not the 22 noted on the cover sheet) It was immediately obvious on
even the most casual review that the Consultant Psychiatrist’s letter must have been
missing its opening page or pages. | However neither the Bognor EI team manager
nor his immediate line manager were aware of this before I drew it to their attention
at the inquest hearing.

There had been no attempt made by the Bognor EI team to contact Mr Roberts
when, on 22 February 2016 (the sixth day following his referral), Mr Roberts took a
large overdose of insulin and his prescribed psychotropic medication.

Mr Roberts was admitted to ICU at St Richard’s Hospital, Chichester in a coma
having suffered significant hypoxic brain damage. In the course of his ICU
treatment a tracheostomy tube was inserted on 2 March 2016. Unfortunately Mr
Roberts died some days later on 7 March 2016 when a rare but recognised
complication of tracheostomy insertion arose. He suffered acute arteritis of the
innominate artery leading to a major haemorrhage at the tracheostomy.

What precipitated Mr Roberts taking the overdose on 22 February 2016 is unknown
and I concluded that it could not be said that Mr Roberts’ overdose would probably
have been prevented had there been an earlier appointment with him made by the
Bognor EI team. Nevertheless, it is of concern that there was no policy, system,
procedure or practice in place that would have ensured that the Bognor EI team
promptly considered relevant clinical information sent by a referrer and used that
information to inform their determination of the patient’s needs and the current
level of risk, and hence the urgency with which their first contact should be made.

Finally, as it was understood that the Avon and Wiltshire Trust would be
conducting their own RCA, there had been no internal review of the events
surrounding Mr Robert’s care conducted by SPFT. The final RCA report from
Avon and Wiltshire Trust, which was completed in June 2016, was not provided to
the SPFT and in any event this report focussed on the role of the Wiltshire services.

Hence those shortcomings I set out above were not identified until the inquest; an
adequate review by SPFT should have revealed matters far sooner.

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) ‘That there was no relevant policy, procedure or practice requiring faxes to the

Bognor EI team be logged and scrutinised on receipt so that it might noted if
faxed pages were missing and potentially important information not received.

(2) That there was no policy, procedure or practice, requiring a member of the EI
team to read written information provided by a referrer before the zoning
meeting and initial risk assessment. Additionally it was practice, on occasions,
for the information to be left unread until shortly before the first face to first
appointment with the patient. Hence the determination of patient’s needs, the
current level of risk and the urgency with which the first contact should be made
with a patient was not informed by all the available information being fully
considered.

(3) That there was no relevant policy, procedure or practice whereby the Bognor El
team would clearly confirm with the referrer the date on which contact with a
newly referred patient would be made.

(4) That SPFT did not appear to have undertaken any formal review of the death of
someone known to the organisation and, although SPFT were aware a RCA was
being conducted by Avon and Wiltshire NHS Trust, SPFT had not received nor
sought that final RCA report from Wiltshire. An opportunity to learn relevant
lessons from the above events had therefore been delayed until the inquest,

almost a year after events.

Nese

ACTION SHOULD BE TAKEN

In my opinion action should be taken to prevent future deaths and I believe 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 7 April 2016. 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.

COPIES and PUBLICATION

I have sent a copy of my report to the Chief Coroner and to the following Interested
Persons:

a

(2) Dr Hayley Richards, Chief Executive, Avon and Wiltshire Mental Health Partnership
NHS Trust.

(3) Ms M Griffiths, Chief Executive, Western Sussex Hospitals NHS Foundation Trust.

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 9 February 2017 9 Bridget Dolan QC LLHO eC of

Responses

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.

Response from Sussex Partnership NHS Trust (PDF)
A member of: INHS|

Association of UK University Hospitals Sussex Partnership

NHS Foundation Trust

5 April 2017
Miss Bridget Dolan QC oe
~ Swandean
Assistant Coroner, West Sussex
; . Arundel Road
Coroner's Office ‘
. Worthing
West Sussex Record Office
West Sussex
Orchard Street BN13 3EP
Chichester
West Sussex
PO19 1DD

Dear Miss Dolan
Re: Inquest into the death of Matthew Christopher Roberts

Thank you for your report written pursuant to the Coroners & Justice Act 2009 and
regulations 28 and 29 of the Coroners (Investigations) Regulations 2013, and for bringing
your concerns to my attention.

Firstly, may | offer my sincere condolences to the parents of Mr Roberts and his extended
family and friends. | am aware that nothing | can say will lessen their grief on the tragic
loss of their son, however, | can make assurances that lessons have been identified and
we have agreed some changes to improve our systems and processes. These are detailed
below, under each of your concerns.

1. That there was no relevant procedure or practice requiring faxes to the
Bognor El team be logged and scrutinised so that it might be noted if faxed
pages were missing and potentially important information not received.

All Sussex Partnership NHS Foundation Trust staff must complete Information
Governance training annually to ensure that information received and sent is managed
safely and effectively. The training includes clear guidance on receiving and sending
faxes. 88% of staff employed in our Early Intervention in Psychosis Services (EIPS) have
completed this training within the last year. Following Mr Roberts’ inquest, the Senior EIP
Management Team identified the need to supplement this training to ensure the
Information Governance Principles were being followed by their staff. Therefore, the team
designed and produced posters setting out the key guidance around the receipt of faxes.
These are displayed above all fax equipment used by EIP staff. Each notice reminds our
staff to pass all faxes promptly to the appropriate recipient, to verify all sent pages have
been received, and that the sender has confirmed their fax has been received. | have also
asked the team to ensure compliance reaches 100% with regards to the Information
Governance Training.

2. That there was no policy, procedure or practice, requiring a member of the El
team to read written information provided by a referrer before the zoning

Chair: Caroline Armitage Chief Executive: Samantha Allen

Head office: Sussex Partnership NHS Foundation Trust, Swandean, Arundel Road, Worthing, West Sussex, BN13 3EP

Www. sussexpartnership.nhs_uk

A teaching trust of Brighton and Sussex Medical School

meeting and initial risk assessment. Additionally it was practice, on
occasions, for the information to be left unread until shortly before the first
face to face appointment with the patient. Hence the determination of the
patient’s needs, the current level of risk and the urgency with which the first
contact should be made with a patient was not informed by all the available
information being fully considered.

The EIP Team Leaders and Senior Clinicians within the EIP service have reflected on this
and have developed a clear set of shared standards for accepting referrals. Key elements
of the standards are:

e All EIP teams to use an updated referral form to gather all relevant information.

e The EIP Practitioner is to confirm receipt of all referrals received by fax on the day
of referral by telephone and to use this telephone call as an opportunity to gather
any further relevant information.

e The EIP Practitioner will take responsibility for ensuring that all referral information
is promptly uploaded or recorded in the patient’s electronic health records; our new
electronic records systems is called ‘Carenotes’.

e The EIP Practitioner is to ensure that an up to date risk assessment is received
from the referrer whenever the referral is from another mental health team within
the Trust or externally, or an initial risk screen is completed in the case of a new
patient, previously unknown to mental health services.

e The EIP Practitioner is to consider all information provided by the referrer, including
information around the presenting risks to help inform them of the clinically
indicated response to the referral.

e The EIP Practitioner is to communicate clearly to the referrer, their provisional plans
for making contact with the referred person and the expected timeframes for this.

e The EIP Practitioner is to record the proposed plans for contacting the referred
person clearly in the patient’s electronic health records on ‘Carenotes’.

e The Daily Zoning meetings will be used to consider all available information on new
referrals and decide the clinically indicated responses.

These key elements have been developed by the Service Manager and the Clinical Lead
of Sussex EIP into a set of guidelines for staff on referrals. These guidelines will be
reviewed and signed off by our Sussex Children and Young People’s Mental Health
Leadership Team by the end of May 2017. Following formal sign off, they will be shared
with all EIP teams and practitioners and support will be provided to embed these expected
standards.

3. That there was no relevant policy, procedure or practice whereby the Bognor
El team would clearly confirm with the referrer the date on which contact with
a newly referred patient would be made.

EIP staff make robust attempts to engage effectively with their service users. Service
users, including those newly referred to the service, are offered a choice around

appointment times and venues for meetings. This helps the service to achieve higher rates
of engagement with service users and better outcomes in relation to patient safety and
service user recovery. Following a referral to the service, an EIP Practitioner will aim to
make telephone contact with the referred client, based on their risk assessment, the next
working day to agree a date and venue for their initial appointment. It is therefore not
always possible to clarify at the point of referral, when the service user will be seen. | am
pleased to say we achieved 95% in February 2017 for the new target for EIP access and
waiting times for assessment and treatment to be within 14 days. In cases where
significant risks are identified, the EIP service recognises the need to make clear plans
around contact and to communicate these clearly and effectively to the referrer and
service user in order to reduce the risk. In cases where the service user does not engage
with us, the EIP team will follow the Trust’s Active Engagement Policy. These elements
are also covered in the recently developed set of guidelines for staff on referrals. A
transition proforma has been developed by the EIP service following your Regulation 28
report. This is a best practice tool for use by EIP Practitioners at the point of transitions
into and out of the EIP service. It requires members of the Multi-Disciplinary Team to
consider risk issues which may present during the transition and formulate clear plans for
responding to these, should they occur.

4. That SPFT did not appear to have undertaken any formal review of the death
of someone known to the organisation and, although SPFT were aware a RCA
was being conducted by Avon and Wiltshire NHS Trust, SPFT had not
received nor sought that final RCA report from Wiltshire. An opportunity to
learn relevant lessons from the above events had therefore been delayed until
the inquest, almost a year after events.

The Trust has developed a new Serious Incident Policy. Justine Rosser, Director of
Nursing Standards and Safety is the lead for this new policy which | anticipate will be in
use Trust wide from next week. This new policy will ensure investigations are carried out to
identify learning without delay and follows NHS England guidelines and best practice. In
future, when another Trust is leading on a Root Cause Analysis, SPFT will complete a
local review and feed into the other Trust’s investigation to ensure maximum reflection and
learning for both organisations is achieved.

Thank you once again for raising your concerns with me. Although you have confirmed it
was not possible to say if the tragic outcome would have been prevented, | take each and
every death of a service user very seriously. To ensure lessons and improvements to
practice are not isolated to one service, the learning from Mr Roberts’ death will be shared,
anonymously, in the Trust’s Quarterly Quality and Safety Report which is circulated Trust
wide and is shared externally with our commissioners (CCGs).

Yours sincerely

Sam Allen
Chief Executive

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