Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0121, written 13 Apr 2017. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 13 Apr 2017 |
|---|---|
| Reference | 2017-0121 |
| Deceased | Luke Moulding |
| Coroner | Ian Pears |
| Coroner area | Bedfordshire and Luton |
| 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 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.
for Bedfordshire and Luton
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
The Chief Executive
East London NHS Foundation Trust |
Corporate Headquarters
9 Alie Street |
London. E1 8DE |
CORONER
| am IAN PEARS, Acting Senior Coroner, for the coroner area of Bedfordshire &
Luton
{
a
i)
2013.
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 |
i
|
\
|
INVESTIGATION and INQUEST
On 18 December 2016 | commenced an Investigation into the death of LUKE
ALF EDWARD MOULDING aged 29. The Investigation concluded at the end of
the Inquest on 5° April 2017. The Conclusion of the Inquest was ‘ACCIDENTAL | |
DEATH’. The medical cause of death was:
1 (a) Severe Traumatic Injuries
1 (b) i
1(c) |
Il Excess Alcohol, Cannabinoids and Opiates Intake
| CIRCUMSTANCES OF THE DEATH
On the 25'* November 2016 the Deceased entered the railway line near his
home in Westoning in Bedfordshire, having consumed alcohol and drugs. Prior
to his death he rang his mother and informed her he was going to get noticed so
t
Senior Coroner, The Court House, Woburn Street, AMPTHILL, Bedfordshire, MK45 2HX
Tel 0300-300-6559 {| Fax 0300-300-8267
he could be arrested and then be helped. In the event he collided with a train
and died from severe traumatic injuries.
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 Deceased saw , Speciality
Doctor in Psychiatry, at Beacon House Community Mental Health Team
on 11 November 2016. The deceased left part way through the
consultation. decided an “opt in” letter was required. It
was not sent.
(2) The evidence is that “opt in” letters are “normally typed and sent by 10
working days.
(3) There seems to be no reason why a typed letter is required. A pre-
printed letter/brochure/card would suffice and give the service users
sufficient information, should they require it.
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and | believe East
London NHS Foundation 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 15" June 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.
COPIES and PUBLICATION
| have sent a copy_of my _r i nd to the following
Interested Persons
| 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
Senior Coroner, The Court House, Woburn Street, AMPTHILL, Bedfordshire, MK45 2HX
‘Fel 0300-300-6559 | Fax 0300-300-8267
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 13' day of April 2017
IAN PEARS
Acting Senior Coroner
for the coroner area of Bedfordshire & Luton
Senior Coroner, The Court House, Woburn Street, AMPTHILL, Bedfordshire, MK45 2HX
Tel 0300-300-6559 | Fax 0300-300-8267
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:
Associate Director of Legal Affairs
Trust Headquarters
8 Alie Street
London
E71 SDE
Telephone: 020 3738 7253
14" June 2017
Acting Senior Coroner fan Pears
The Court House
Woburn Street
Ampthill
Secfordshire
MEAS 24X
Dear Sir
inquest touching upon the death of Luke Mouiding
This is a formal response to your Regulations 28 Report dated 13" April in which you
Set out your concems relating to the care Mr Moulding received from East London
NHS Foundation Trust.
Your concerns related specifically to a delay in sending Mr Moulding an ‘opt-in’ letter
following his last appointment with a psychiatrist at the Community Mental Health
Team (CMHT) on 11" November 2016,
| understand that you were assisted at the Inquest by statements from staff involved
in Mr Mouiding’s care. The psychiatrist who saw Mr Moulding on 11° November
hightighted in her statement that Mr Moulding had left his appointment stating that he
did not wish to engage with the CMHT. Following this appointment the psychiatrist
had decided that Mr Moulding should be sent an ‘opt-in’ letter setting out that he stil!
had the option to call the CMHT for an appointment if he wished. The psychiatrist set
out that opt-in letters are normally typed and sent within 10 working days. However,
this had not been sent at the time of Mr Moulding’s death.
it appears that your concern is around the timing of such a letter and you suggest
that a pre-printed letter could be sent providing sufficient information, thereby cutting
down on any delay incurred by waiting for the letter fo be typed.
Pe Chief Executive: Dr Navina Evans
Following Mr Moulding's untimely death the Trust undertook a Serious Incident
Review. This review identified the delay in sending Mr Moulding an opt-in letter as a
care delivery problem.
The reviewer's identified that the Operational Policy for the CMHT did not provide
guidelines on the service timescales for providing apt-in letters and were concerned
to find that the lead time in November 2016 was up to 30 days. it was therefore
recommended that ihe Operational Policy be updated to provide appropriate
timescaiss.
Action was subsequently undertaken to the Operational Policy which now requires
that opt-in letters should be sent within 5 working days. Compliance against this
timescale will be the subject of local audit to ensure compliance.
Whilst a pre-printed letter was not thought to be suitable, { hope that the action taken
provides you with assurance that the Trust has taken appropriate action and that
your concerns have been adequately addressed.
if you do require any further information please do not hesitate to contact me.
Yours faithfully
PF Chief Executive: Dr Navina Evans
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