Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0048, written 23 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 | 23 Feb 2017 |
|---|---|
| Reference | 2017-0048 |
| Deceased | Grant Burns |
| Coroner | Grahame Short |
| Coroner area | Southampton and New Forest |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Solent NHS Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
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Grahame Antony Short Senior Coroner for Southampton & New Forest REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Solent NHS Trust CORONER lam Grahame Antony Short, Senior Coroner for Southampton & New Forest 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. http://www. legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http:/Awww. legislation. gov .uk/uksi/2013/1629/part/7/made INVESTIGATION and INQUEST On 29/07/2016 | commenced an investigation into the death of Grant David Burns, 35. The investigation concluded at the end of the inquest on 30 January 2017. The conclusion of the inquest was this was a Drug related death. CIRCUMSTANCES OF THE DEATH At an unknown time between 20.05 on 22 July and 15.15 on 23 July 2016 whilst alone in room it The Booth Centre 57 Oxford Street Southampton Grant Burns took an excess quantity of methadone, heroin and Alprazolam. He died due to Morphine, Methadone and Alprazolam Toxicity. Grant Burns had a dual diagnosis of paranoid schizophrenia and drug and alcohol abuse. 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 death was the subject of Root Cause Analysis report by Southern Health NHS Foundation Trust who provided the Early Intervention in Psychosis Service (EIPS) for the deceased, which found there was a lack of co-operative working between the EIPS and the Substance Misuse Service based at New Road Southampton provided by Solent NHS Trust (2) The Southern Health report highlighted that their report was incomplete because there was no input from the key worker at New Road despite best efforts (3) There was a lack of communication between partner agencies Coroner's Office, Castle Hill, The Castle, Winchester, $023 8UL Tel 01962-667884 | Fax 01962-667893 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you Solent NHS Trust 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 14 April 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. COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the following Interested Persons: Southern Health NHS Foundation Trust and | 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. Dated 23 February 2017 ? Signature < Senior Coroner for Southampton & New Forest Corouer's Office, Castle Hill, The Castle, Winchester, SO23 8UL, Tel 01962-667884 | Fax 01962-667893
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.
By 1235°-20lG (wp Solent INHS NHS Trust Solent NHS Trust Headquarters Highpoint Venue Bursledon Road Southampton $019 8BR 5" April 2017 Mr Grahame Antony Short Coroner’s Office Castle Hill The Castle Winchester $023 8UL Dear Mr Short, Regulation 28 Report to Prevent Future Deaths: Grant David Burns After a full assessment, it has been found that in this incident there was a lack of co-operative working between Southern Health mental health services (Early Intervention in Psychosis Team) and Substance Misuse Services. After some discussion, the action now required is to compile a spread- sheet of those clients identified as being worked with by Adult Mental Health and Substance Misuse Services. This spread-sheet needs to be updated at the Southampton Drug and Alcohol Recovery Service Management meeting with regular communication with Southern Health Foundation Trust. This action was put in place on the 27" of March 2017 and is due to end on the 1th of April 2017. The desired outcome of this action is to improve clients’ experience of services, working cohesively and consistently to support risks and the individuals’ recovery. There is evidence that the spread-sheet was completed on Wednesday 20" March 2017 and has been added to the weekly Joint Clinical Meeting Agenda for Monday the 10" April 2017. It has also been added to the Solent morning meeting agenda as a standing item twice weekly. The second action concerns referrals which are screened in Substance Misuse Services. The Change Grow Live Manager with the Solent NHS Trust Clinical Manager will identify if there is any involvement from mental health services. If Adult Mental Health is involved, contact is to be made via telephone call/letter or email with the mental health treating team to make them aware that the Substance Misuse Services are also involved in the patient’s care. A meeting will then be arranged to start the joint working process. A named staff member will be identified to take responsibility for this action, which will usually be the Change Grow Live Care Co-Ordinator. Should there be no response from the mental health team following the substance misuse workers making contact, they will escalate this to their line manager to raise with the Area Manager — Southampton Mental Health Team Manager. This action was put in place on the 3” of April 2017 and will end on the 10" of April 2017. The third action is to review the Dual Diagnosis Policy within Southern Health Foundation Trust and Solent NHS Trust to ensure that the action above is included within it as best practice for staff to follow. This action commenced on the 3% of April 2017 and is due to end on the 1° of May 2017. at Moy, ‘4 ‘ We $ & ) ed BANS INVESTOR IN PEOPLE Solent NHS Trust Headquarters, Highpoint Venue, Bursledon Road, Southampton SO19 8BR Telephone: 023 8060 8900 Fax: 023 8053 8740 Website: www.solent.nhs.uk The fourth action is to undertake an annual audit of compliance against the standards set within the policy. This is due to be put in place in September 2017 and will end in April 2018. In relation to issue 2, namely the report being incomplete because there was no input from the key worker at New Road, a number of actions have been put in place. In this particular instance, the incomplete reports were due to lack of input from both Substance Misuse Services and Adult Mental Health in relation to Serious Incident Requiring Investigation reports. In order to avoid this from happening again an action has been put in place to review the current Serious Incident Requiring Investigation policies for Southern Health Foundation Trust and Solent NHS Trust to ensure the explicit requirement of Serious Incident requiring investigation investigators to engage with all key stakeholders/services who were/are involved in a persons’ care, and offer them input into the investigation process. This action was put in place on the 3” of April 2017 and is due to end on the 1* of May 2017. The desired outcome of this action is to ensure that policy mandates the requirement for Serious Incident Requiring Investigation Investigators to ensure that all known stakeholders and services are involved in the completion of the report. Action 6 is to undertake an annual audit of compliance against the standards set within the policies. This action will be put in place in September 2017 and will end in April 2018. Finally the seventh action is with regard to the third issue of the lack of communication between partner agencies. The action is to create a bespoke Joint Working Practice document to outline the standards expected of staff in Substance Misuse Services and Adult Mental Health with regard to communication between organisations where patients are supported by both. These standards should cover, though are not limited to: Frequency of contact; Joint visits/meetings and escalation process. This action commenced on the 3” of April and is due to end on the 18" of April 2017. The outcome of the action is to maintain consistent shared knowledge of patients’ risks and needs, and how these can be addressed. It is anticipated that there will then be a clear understanding by patients and carers regarding the involvement of different services, including their roles and functions. Finally the eighth action is to undertake an annual audit of compliance against the standards set within the policies. This action is due to be put in place in September 2017 and will end in April 2018. Yours sincerely —_ = —_ Manager
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