Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0093, written 14 Mar 2017. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 14 Mar 2017 |
|---|---|
| Reference | 2017-0093 |
| Deceased | Mariana Pinto |
| Coroner | Mary Hassell |
| Coroner area | Inner North London |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | East London NHS Foundation Trust |
| 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: Prevention of Future Deaths report
Mariana Hungria Bayam Veiga PINTO (died 16.10.16)
THIS REPORT IS BEING SENT TO:
1.
Medical Director
East London NHS Foundation Trust
Trust Headquarters
9 Alie Street
London E1 8DE
1
CORONER
I am: Coroner ME Hassell
Senior Coroner
Inner North London
St Pancras Coroner’s Court
Camley Street
London N1C 4PP
2
CORONER’S LEGAL POWERS
I make this report under the Coroners and Justice Act 2009,
paragraph 7, Schedule 5, and
The Coroners (Investigations) Regulations 2013,
regulations 28 and 29.
3
INVESTIGATION and INQUEST
On 19 October 2016, I commenced an investigation into the death of
Mariana Hungria Bayam Veiga Pinto. The investigation concluded at the
end of the inquest on 13 March 2017. I made a narrative determination at
inquest, which I attach. I recorded the medical cause of death as:
1a multiple injuries including ruptured left kidney.
4
CIRCUMSTANCES OF THE DEATH
Mariana Pinto jumped from the third floor balcony of her home as a
deliberate act, but without a proper understanding of what she was doing.
1
She had attended the emergency department of the Homerton University
Hospital the day before and had been assessed as not detainable under
the Mental Health Act.
On the day of her death, her husband called the City and Hackney Crisis
Line at lunch time and was told that she would receive a home visit
between 5 and 7pm. He then called back at 3.32pm, explaining that his
wife was deteriorating rapidly and needed to see someone urgently.
Half an hour later, Mariana Pinto jumped.
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. It seemed to me at inquest that, when Ms Pinto left the emergency
department the day before her death, the limitations of the crisis team
were not made clear to her family and friends.
2. The view of the psychiatrists treating Ms Pinto in the emergency
department was that she was suffering cannabis withdrawal, which I
heard is generally at its worst during the first three days.
Her symptoms were now quiescent, but it would have been very
helpful for her family to know that, most particularly as she had taken
cannabis the night before, once the lorazepam wore off she might well
have a resurgence of symptoms though these were not expected to
be as severe as they had been. Worsening advice could then have
been delivered in this context, with a clear plan of action.
It is a theme I have noticed in deaths such as Ms Pinto’s, that
clinicians’ expectations of illness progression are not necessarily
communicated effectively to families, to enable families to identify
unexpected deterioration and then to act swiftly and appropriately.
3. The band 7 mental health nurse who took the call to the crisis line at
3.32pm on 16 October, did not suggest to Ms Pinto’s husband that
call the emergency services while the nurse rang Ms
Pinto and spoke to her to offer what support he could.
When
nurse responded that the time for home visits was 5-7pm.
told him that the situation was now urgent, the
2
After the call had ended, the nurse did not discuss with colleagues the
potential to bring the home visit forward.
The nurse did not ring the emergency services himself in case
had been unable to make the call.
6
ACTION SHOULD BE TAKEN
In my opinion, action should be taken to prevent future deaths and I
believe that you 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 22 May 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 following.
HHJ Mark Lucraft QC, the Chief Coroner of England & Wales
Care Quality Commission for England
, crisis team member
, husband of Mariana Pinto
, emergency physician, Homerton Hospital
, psychiatrist, City & Hackney
, crisis team member
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
interest. You may make
representations to me, the Senior Coroner, at the time of your response,
about the release or the publication of your response by the Chief
Coroner.
it useful or of
find
3
9
DATE SIGNED BY SENIOR CORONER
14.03.17
4
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.
East London NHS Foundation Trust Please respond to: Jane Quinn Associate Director of Legal Affairs Trust Headquarters 9 Alie Street London E1 8DE Telephone: 020 3738 7253 22" May 2017 Senior Coroner M E Hassell Inner North London Poplar Coroner's Court 127 Poplar High Street London E14 0AE Dear Madam Inquest touching upon the death of Mariana Pinto This is a formal response to your Regulations 28 Report dated 14" March in which you set out your concerns relating to the care Ms Pinto received from East London NHS Foundation Trust. Your concerns related to the following three points: e Limitations of the crisis team were not made clear to Ms Pinto’s family and friends. e Provision of information regarding a possible resurgence of symptoms as a result of cannabis withdrawal and advice on a clear plan of action. e The handling of the phone call to the crisis line made by Ms Pinto’s husband at 3:32pm on 16 October. | will address each of your concerns in turn below. lam aware that you heard evidence during the course of the Inquest that following psychiatric assessment in A&E Ms Pinto had been referred to the Home Treatment Team (HTT). Chair: Marie Gabriel Chief Executive: Dr Navina Evans You were informed by witnesses that the HTT does not provide an emergency service and in the event that emergency assistance is required assistance the individual should attend A&E with assistance sought from Police or Ambulance services when required. | acknowledge that although the family were provided with crisis information on discharge they were not clear about the limitations of the HTT in relation to providing an emergency response. It is obviously important to ensure that both the patient and relatives/carers are aware of the steps to take should there be a serious deterioration in an individual's mental state. Having considered your concern | am confident that this will be addressed by the formulation of a written discharge care plan which is currently being developed and will in future be provided to all service users/relatives prior to discharge from A&E following a psychiatric assessment. This care plan will set out who the service user was seen by, what the follow up plan is, contact details for relevant services and when an individual should expect to be contacted. Advice on when to seek urgent help and what to do in the event of an emergency will be included in this care plan, which will also deal with the concerns you have raised in relation to advice about resurgence of symptoms, what to look out for and what action to take in response. | acknowledge that attending A&E and undergoing a psychiatric assessment can be a stressful and confusing experience for an individual and their relatives. | consider that the provision of a written discharge care plan will prove to be a useful tool. A template for this care plan has been drafted and will be presented at the Hackney Service User Focus Group at the end of this month. Following consultation with service users and carers this will be implemented. | am informed that Ms Pinto’s mother-in-law will be providing views as a carer representative as part of the consultation process. In relation to your final point regarding the handling of the call made by Mr Parra- Braun on the afternoon of 16" October it is important to confirm that in an emergency situation advice to contact Police and Ambulance is an appropriate and robust response. | believe that your specific concern related to what support the HTT could have provided in the interim, for example the member of staff attempting to speak to the service user to deescalate the situation and/or personally contacting the emergency services. Direct contact with the emergency services by mental health staff is not straight forward where family or friends are in attendance at the scene, as Police and Ambulance services require as much information as possible in relation to access and a description of the current situation from relatives or carers. However, in the event that a service user is on their own at a time of crisis then staff could intervene to call an ambulance or request that the Police attend to conduct a welfare check. Advice on de-escalation of a crisis is a role that is fulfilled by the HTT. This can be in the form of advice at the time of a call to the crisis line or a return call following the advice to contact the emergency services. It is the standard practice of the team to follow up on calls to the emergency services either by telephone or in person. Whether to speak to a service user directly whilst their relative contacts emergency services need to be carefully considered on a case by case basis. Chair: Marie Gabriel Chief Executive: Dr Navina Evans. | understand that you heard evidence during the course of the Inquest that additional funding had been secured for the HTT and from October 2017 the team will have increased flexibility to bring forward visits to those service users who experience a deterioration in their mental health between scheduled visits. From October 2017 the service will be reconfigured to provide the availability for 24 hour face to face contact if required and an enhanced urgent response service. The City and Hackney Home Treatment Team had previously operated one shift only each day of the weekend, with a morning shift on a Saturday and an evening on Sunday. This has since been changed to providing both a morning and an evening shift to improve provision of visits on the weekend. With the changes already undertaken and those planned for implementation over the coming months | hope you will be content that the Trust has taken these issues seriously and adequately addressed your concerns. If you do require any further information please do not hesitate to contact me. Yours faithfully Dr Kevin Cleary Chief Medical Officer Chair: Marie Gabriel Chief Executive: Dr Navina Evans
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