Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0172, written 28 May 2017. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 28 May 2017 |
|---|---|
| Reference | 2017-0172 |
| Deceased | Jamie Pashley |
| Coroner | Julian Morris |
| Coroner area | London Inner (South) |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | King's College Hospital NHS Foundation Trust · South London and Maudsley 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.
ANNEX A REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. South London and Maudsley NHS Trust 2. Kings College Hospital : 3. Secretary of State for Health 1 | CORONER i am Dr Julian Morris, assistant coroner, for the coroner area of Inner London South 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 | commenced an investigation into the death of Jamie Pashley, aged 32. The investigation concluded at the end of the inquest on 7 November 2016. The conclusion of the inquest was accidental death caused by alcohol intoxication. The medical cause of death was 1a Alcohol intoxication, II Alcoholic liver disease. Jamie died on 26 August 2015. 4 | CIRCUMSTANCES OF THE DEATH Jamie presented to the medical services and was acknowledged as suffering from an alcohol problem requiring detoxification in January 2015. He had had a 2 year escalation of intake. He was abstinent for 21/2 months before starting, under control, again. On 4 August 2015 he was admitted to KCH following an alcohoi withdrawal seizure. He completed his detoxification and was discharged on 7 August 2015. He was asked to proactively engage with Lorraine Hewitt House alcohol team and/ or | Lambeth IAPT (improving access to psychological services). He saw his GP on 14 | August 2015 when he was started on anti-depressants. He had a telephone contact with Lambeth Talking Therapies on 20 August and was advised, due to his alcohol, to engage with the alcohol service first. He was found in his flat on 26 August 2015. Subsequently, he was found to have high leveis of alcohol in his body. 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. — Whiist understanding and appreciating that dealing with anxiety and alcohol dependence can be difficult, and taking into account the issue of resources, | would ask that the reliance upon an individual to proactively manage their rehabilitation be reviewed and te-assessed. Issues concerning the younger generation and alcohol are increasing and with the risk of relapse being potentially higher in the time soon after discharge | would ask that the following be reviewed: (1) whether, upon discharge after detoxification, individuals ought, in addition to receiving information regarding access to Lorraine Hewitt House Aftercare Programme and signposting them to a drop in clinic, to be provided with a fixed appointment; (2) whether telephone contact should also be made with an individual between discharge and first appointment review; (3) whether there is a need to increase the availability of an alcohol liaison nurse currently provided between the hours of 0900-1700,Monday to Friday, at the hospital for the individual to access, given they have met that person whilst an in-patient. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you AND/OR your organisation 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 25 August 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 report to the Chief Coroner and to the following Interested — who may find it useful or of interest. | 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. 28 May 2017 Dr Julian Morris
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.
King’s College Hospital NHS Foundation Trust Your ref: 02257-2015 , Legal Services Our ref; PBY/PASHLEY(5244) King’s College Hospitai Denmark Hilf London SES 9RS 19 July 2017 Tel: 020 3299 3320 . . . Fax: 020 3299 3706 Assistant Coroner Dr Julian Morris Southwark Coroner's Court 1 Tennis Street Southwark London SE11YD Dear Dr Morris RESPONSE TO REGULATION 28 REPORT TO PREVENT FUTURE DEATHS: JAMIE PASHLEY (DECEASED) We write further to the above Report dated 28 May 2017 and detail the Trust’s formal response below. We note that you have raised concerns about the level of reliance placed on those with alcohol dependence to proactively manage their rehabilitation in light of the Inquest touching the death of Jamie Pashley which concluded on 7 November 2016. , We further note this Report has also been sent to South London and Maudsley NHS Foundation Trust as well as to the Secretary of State for Health, who are likely to be in a position to provide additional information from a wider viewpoint to address your concerns. Concern One Upon discharge after detoxification, should individuals, in addition to receiving information regarding access to Lorraine Hewitt House Aftercare Programme and signposting them to a drop-in clinic, be provided with a fixed appointment? Trust response: Alcohol dependency patients have notoriously very high DNA rates. As a result, providing fixed follow-up appointments for this category of patients after detoxification as an in-patient and signposting would likely generate a high level of wasted appointments. This is why it is common practice within the NHS to instead use motivational models and to ensure patients as far as practicable are linked in with appropriate third-sector services prior to discharge rather than providing further hospital appointments. In Mr Pashiey’s case, he had been making good progress with his alcohol- withdrawal therapy and at his review with the Substance Misuse Liaison Nurse on 7 August 2015, she noted Mr Pashley had himself already made contact with the Community Psychological Services and was booked in for an assessment on 27 | 1} bt sit b@ KING'S HEALTH PARTNERS An Academic Health Sciences Centre for London Pioneering better health for all i if i i i] t August 2015. The Nurse also encouraged him to access support available at Lorraine Hewitt House in the interim, prior to the IAPT assessment, which Mr Pashley agreed to do. Post-discharge, Mr Pashley saw his GP on 14 August 2015 and had telephone contact with Lambeth Talking Therapies on 20 August 2015. The Trust recognises that providing a fixed repeat appointment may be beneficial for some alcoho! dependency patients but it is unclear how effective this would be in ensuring patients access other specialist third-sector services subsequently. In Mr Pashley's case, he saw his GP in the interim period but this was sadly unable to change the outcome. The Trust's view is that a more assertive follow-up approach prior to discharge in addition to arranging an appointment with the patient's GP may be a more effective approach. There is currently a trial underway in which King’s College Hospital is taking part around this new approach, which we hope will be beneficial to such patients going forwards. Concern Two Should telephone contact also be made with an individual between discharge and first appointment review? Trust response: As is the case with the the provision of fixed appointments, the Trust recognises that making telephone contact in this interim period may be beneficial for some alcohol dependency patients. However, it is again unclear how effective this would be in ensuring patients access other specialist third-sector services subsequently. Additional funding would be required to expand the alcohol dependency service within the Trust, which would then allow for more contact with the patient. Concern Three Is there a need to increase the availability of an alcohol liaison nurse currently provided between the hours of 0900-1700, Monday to Friday, at the hospital for an individual to access, given they have met that person whilst an in-patient? Trust response: The Trust currently employs one Alcohol Liaison Nurse who deals with the alcohol dependency patients on wards. She performs checks on the quality of their detoxification, and links them in with Lifeline (an organisation involved with various abuses and addictions, which has since ceased operation and been replaced with CGL (Change, Grow, Live)). The Trust acknowledges that there is demand for an increased team so that patients can access staff that they worked with whilst an in-patient. Various approaches have been made to local CCGs and charities without success to date, and so the Trust is considering a business case to increase the Alcohol Liaison team. The benefits to i i" the Trust would likely be the reduction of ED attendances and reduction of admissions in particular. The Trust is committed to continually improving its services so that patient safety remains the priority. On behalf of the Trust, we would like to express our deep condolences to Mr Pashley's family, and wish them well for the future. Please do not hesitate to contact us should you require any clarification or further information. Kind regards Yours sincerely KCH Legal Services
See every Prevention of Future Deaths report matching King's College Hospital NHS Foundation Trust, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.