Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0135, written 25 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 | 25 Apr 2017 |
|---|---|
| Reference | 2017-0135 |
| Deceased | Jamie Elliott |
| Coroner | Edwin Buckett |
| 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
Jamie Neil Elliott (died 18.11.2016)
THIS REPORT IS BEING SENT TO:
Dr Navina Evans
Chief Executive and Director for Mental Health
East London NHS Foundation Trust
Trust HQ
The Green
1 Roger Dowley Court
London E2 9NJ
1
CORONER
I am: Edwin Buckett
Assistant Coroner
Inner North London
Poplar Coroner’s Court
127 Poplar High Street
London E14 0AE
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 23rd November 2016 I began an investigation into the death of Jamie
Neil Elliott who died aged 52 on the 18th November 2016 at his home
address at
.
The investigation concluded at the end of the inquest into his death on
21st April 2016 which was conducted by myself.
I made a determination at inquest that the deceased died as a result of
hanging on the 18th November 2016 with a conclusion of suicide.
4
CIRCUMSTANCES OF THE DEATH
On the 10th August 2016 Jamie Elliott referred himself to the Trust
1
presenting with thoughts of suicide.
Between that date and the 18th November 2016, he was seen by the
Home Treatment Team on numerous occasions and was assessed by a
Consultant Psychiatrist from the Trust on the 20th October 2016 with
further contact with that clinician on the 27th October and 10th November
2016.
Jamie also called the Trust Crisis Team frequently in the 3 months prior
to death.
I found that during this 3 month period, Jamie expressed clear, detailed
and escalating suicidal ideations such that he was offered voluntary in-
patient admission on the 10th, 13th and 15th November, 2016 but he
declined this.
Consideration was given
to compulsorily detaining him however,
clinicians from the Trust were fortified by the fact that Jamie appeared to
be receiving private therapy, 3 times a week, from a therapist elsewhere
and therefore the fact he was taking some medication and receiving this
treatment were factors which weighed in the balance against compulsorily
detaining him.
In fact, no contact was made between clinicians from the Trust and that
private therapist to: (i) verify that treatment (ii) ascertain how Jamie was
responding to therapy and (iii) identify whether he was also expressing
suicidal ideation to that individual.
Had such contact been made clinicians from the Trust would have been
in a better position to consider whether to compulsorily detain Jamie and
the outcome in Jamie’s case may have been different.
It was also clear that clinicians from the Home Treatment Team assumed
that the contact between Jamie and the Consultant Psychiatrist on the
10th November, 2016 was a face to face psychiatric assessment when
this had not been the case. His condition had clearly deteriorated by this
time and he was not given a psychiatric assessment on the 10th
November or after this date.
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.
Evidence was given by the Trust that a Serious Incident Review had
identified areas of concern but no changes had been implemented and it
2
was not clear when any of the suggested changes would actually be
made. My concerns are:
1. Mental health clinicians from the Trust should be required to
contact external providers of mental health services, if possible,
when a patient is receiving treatment elsewhere, particularly when
consideration is being given to compulsorily detain that individual.
They should not simply take the patient’s account at face value.
2. There should be a psychiatric assessment, by a Consultant
Psychiatrist in circumstances where there is a referral to the Home
Treatment Team where a patient’s condition has worsened. Ideally
this should be within 48 hours and should be a face to face
psychiatric assessment.
6
ACTION SHOULD BE TAKEN
In my opinion, action should be taken to prevent future deaths and I
believe that you and/or 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 27th June 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 Q.C. the Chief Coroner of England and Wales;
The family of Jamie Elliott.
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
interest. You may make
he believes may
representations to me, the 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 25.4.2017 SIGNED BY ASSISTANT
CORONER EDWIN BUCKETT
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 re: Associate Director of Legal Affairs Trust Headquarters 9 Alie Street London E1 8DE Telephone: 020 3738 7253 27" June 2017 Assistant Coroner Edwin Buckett Inner North London Poplar Coroner's Court 127 Poplar High Street London E14 OAE Dear Sir Inquest touching upon the death of Jamie Elliott This is a formal response to your Regulations 28 Report dated 25" April in which you Set out your concerns relating to the care Mr Jamie Elliott received from East London NHS Foundation Trust. Your concerns related to the following two points: ¢ Mental health Clinicians from the Trust Should be required to contact external providers of mental health services, if Possible, when a patient is receiving treatment elsewhere, Particularly when consideration is being given to compulsorily detain that individual. They should not simply take the patient's account at face value. There should be a Psychiatric assessment by a Consultant Psychiatrist in circumstances where there is a referral to the Home Treatment Team where a patient's condition has worsened. Ideally this should be within 48 hours and Should be a face to face psychiatric assessment. As you will be aware these issues were highlighted in the Trust's Serious Incident Review and [ understand that you wished to receive assurance that the recommendations made had been implemented by the Trust. In relation to contact with external providers ! can confirm that a memo has been distributed to all clinical Staff in City and Hackney highlighting the issue. po Chief Executive: Dr Navina Evans [oo In relation to face to face ° Referrals who have ni Prioritise review, ° Referrals who referral will be emergency this will be | hope that the above Additionally, this issue is due to be discussed This forum is where learning from incidents is representative members of every borough team for further dissemination to their teams. Provided by the on If you require any further information please do not Yours faithfully oo at the Learning Lessons Forum in July, Presented and spread to psychiatric assessments by the Home Treatment team the Operational Policy has been updated to include the fol following: 48 hrs of referral should be highlighted by whoever accepts the referral to one have not been Seen by a health care Professional prior to seen by a doctor Medical review is required outside routinely within a maximum of 72 hours, if of norma! working hours then Call psychiatry service. ove information assures you that the Trust has taken these issues: Seriously and that your concerns have been addressed. hesitate to contact me. Chief Executive: Dr Navina Evans
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