Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0031, written 8 Feb 2017. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 8 Feb 2017 |
|---|---|
| Reference | 2017-0031 |
| Deceased | David Read |
| Coroner | Jacqueline Lake |
| Coroner area | Norfolk |
| 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 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Chief Executive Michael Scott - Norfolk & Suffolk NHS Foundation Trust Trust Management 1%‘ Floor Admin Hellesdon Hospital Drayton High Road Hellesdon | Norwich, NR6 5BE 1 | CORONER lam JACQUELINE LAKE, Senior Coroner, for the coroner area of NORFOLK 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. 3 | INVESTIGATION and INQUEST On 4 July 2016 | commenced an investigation into the death of DAVID SEAN READ, AGE 29 years. The investigation concluded at the end of the inquest on 23 January 2017. The medical cause of death is 1a) Mixed Drug and Alcohol Toxicity which includes Heroin Toxicity and the conclusion of the inquest was Drug and Alcohol Related 4 | CIRCUMSTANCES OF THE DEATH Mr Read lived at Herring House Trust, 51 St Nicholas Road, Great Yarmouth, Norfolk. , On 1 July 2016 Mr Read collapsed after injecting heroin. He was taken to James Paget University Hospital by paramedics where he died on 3 July 2016. 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) Mr Read was referred to the Crisis and Resolution Home Treatment Team by his GP on 24 February 2016 as an urgent referral and was duly seen that evening when it was decided there should be input from the Community Mental Health Team. (2) On 25 February 2016 Mr Read was referred by a Social Worker at Herring House, where he was residing, to the Community Mental Health Team and he was given an appointment for 21 March 2016, under 4 weeks from the date of the initial referral. (3) This appointment was cancelled by Mr Read (no reason is recorded for the cancellation but Mr Read did start alcohol detoxification on this date) and his name was added to the waiting list for a fresh appointment to be arranged. (4) The appointment was treated as a new referral and a new appointment date was sent out on the 18 May 2016 with a new appointment date of 14 July 2016. This is in excess of 16 weeks after the re-referral. Sadly Mr Read died in the meantime. 6 | ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe 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 10 April 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: ME «cine. | 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. BFebruary 2017 (— eaeeueneeees ate, vee esenaeneneneaeeneeeeess Jacqueline Lake Senior Coroner for Norfolk -
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.
p 2 1s ae Tel: 01603 421421 Fax: 01603 421440 www.nsft.nhs.uk & ABOy, Chair: Gary E Page S Chief Executive: Michael Scott WI: fancns Trust Headquarters: Hellesdon Hospital, Stonewall laguesh 22> I | 7 Norfolk and Suffolk NHS) NHS Foundation Trust 11 APR 2017 Trust Management 1° Floor Admin Hellesdon Hospital Drayton High Road Hellesdon Norwich NR6 5BE Our Ref: MS/mp 5 April 2017 Private and Confidential Ms J Lake HM Coroner Norfolk Coroner’s Service 69-75 Thorpe Road Norwich Norfolk NR1 1UA Dear Ms Lake Regulation 28 report following the inquest of Mr David Read on 23 January 2017 | write in response to your report dated 8 February 2017. Under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 you requested the Trust consider issues of service delivery following the conclusion of the inquest into the death of Mr Read on 23 January 2017. You recorded the details of Mr Read’s contact with the Trust in the period prior to his death, identifying that after cancelling the first appointment with the community mental health team, due for 21 March 2016, the new appointment was arranged for 14 July 2016. Mr Read died in between this time. Reflecting on this period of time, it is observed there were a number of challenges within the team with respect to vacancies and staff on maternity leave. These had an impact on the team’s ability to offer appointments. Subsequent to this period, recruitment to vacancies means the team is currently fully staffed. The team have also made amendments to practice since this time and proposed additional actions upon reflection of your report, with the intention to develop patient safety and experience. These are detailed below. - Ifa service user does not attend an appointment they will have a phone call to rearrange an appointment instead of sending a letter. - The service user will no longer get a letter stating that they have been put on a waiting list. - The service user will be given the phone number for the duty worker so if they experience change in their circumstance before attending their appointment they can speak to someone. - Any phone calls to the team or duty worker raising concerns are documented on Lorenzo (the electronic patient record system) and communicated within the team. Drayton High Road, Norwich, NR6 5BE DIVERSITY CHAMPION Ms Lake -2- - The clinical team leader monitors cases that have an appointment pending on a daily basis, taking account of any phone calls or concerns and allocates them a sooner appointment based on the assessment of potential change in risk. Thank you for raising this matter of concern, which has assisted the Trust to consider further learning that can be made. If | can be of any further assistance please do not hesitate to contact me. Yours sincerely Michael Scott Chief Executive Chair: Gary E Page Chief Executive: Michael Scott MINDFUL Trust Headquarters: Hellesdon Hospital, Stonewall EMPLOYER Drayton High Road, Norwich, NR6 5BE DIVERSITY CHAMPION Tel: 01603 421421 Fax: 01603 421440 www.nsft.nhs.uk
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