Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0177, written 24 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 | 24 May 2017 |
|---|---|
| Reference | 2017-0177 |
| Deceased | Dominic White |
| Coroner | Mary Hassell |
| Coroner area | Inner North London |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Whittington Health NHS Trust · Barnet, Enfield and Haringey Mental Health NHS Trust · Camden and Islington 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
Dominic Michael WHITE (died 10.11.16)
THIS REPORT IS BEING SENT TO:
1. Mr Simon Pleydell
Chief Executive
Whittington Health NHS Trust
Whittington Hospital
Magdala Avenue
London N19 5NF
2.
Medical Director
Barnet, Enfield & Haringey Mental Health NHS Trust (BEH)
St Ann’s Hospital
St Ann’s Road
London N15 3TH
3. Ms Wendy Wallace
Chief Executive
Camden & Islington NHS Foundation Trust (C&I)
4th Floor, East Wing
St Pancras Hospital
4 St Pancras Way
London NW1 0PE
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
1
On 14 November 2016, one of my assistant coroners, William Dolman,
commenced an investigation into the death of Dominic White aged 27
years. The investigation concluded at the end of the inquest on 19 May
2017. The jury made a narrative determination, a copy of which I attach.
4
CIRCUMSTANCES OF THE DEATH
Dominic White had diagnoses of bipolar affective disorder and psychosis,
but had been well for some time. However, in the few days before his
death he very rapidly deteriorated.
His parents took him to the emergency unit at the Whittington Hospital on
Monday, 7 November; they called the crisis team at Canning Crescent for
help on Tuesday, 8 November; and they returned to hospital with him via
ambulance on Wednesday, 9 November.
He spent most of 9 November in the emergency unit and was assessed
as requiring detention under section 2 of the Mental Health Act, but
before being conveyed to a mental health hospital with space for him, he
walked out of the hospital emergency unit where he had been assessed.
He was found the following day at an electricity substation, with injuries
consistent with a fall from height. There was no evidence that any other
person was involved in his death, but he lacked the necessary insight or
intent to allow a determination of suicide to be a safe one.
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.
Many issues were raised at inquest, but I was given information that the
majority of these had been explored in advance of the hearing, and new
ways of working had been found. The MATTERS OF CONCERN that
remain, are as follows.
1. I heard that, following Mr White’s death, the level of (mental health)
observations of a patient at the Whittington Hospital Emergency
Unit is now clearly documented.
However, I am not sure that there is yet a robust protocol in place
to ensure that all relevant personnel (Whittington EU doctors,
nurses and security officers; also visiting independent s12 doctors,
BEH and C&I staff) are aware of the level.
2
My concern arises because sometimes, when anyone can look at
a record, that nobody actually does.
2. The C&I approved mental health professional (AMHP) who gave
Mr White permission to leave the hospital to go to McDonald’s,
after the decision had been made to detain him under section 2 of
the Mental Health Act, acknowledged that she should have
discussed this first with a colleague.
However, she remained of the view at inquest that the decision
itself had been the right one. Proof of this, she explained, was the
fact that Mr White did return to the hospital from this visit.
Allowing leave in these circumstances was a very unusual step I
am concerned at the lack of recognition, even so long after the
event, that allowing a person to leave the hospital in these
circumstances:
- was not necessarily the right one simply because the patient
returned on this occasion (he left again within half an hour and
never returned); and
- had the potential to lull others into a false sense of security about
his risk of absconding.
The trust’s root cause analysis action plan merely describes the
need to have legally authorised permission to leave, without
addressing any question of how to shape clinical decision making.
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 24 July 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.
3
HHJ Mark Lucraft QC, the Chief Coroner of England & Wales
Care Quality Commission for England
, approved mental health professional
, parents of Dominic White
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 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
9
DATE SIGNED BY SENIOR CORONER
24.05.17
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.
Whittington Health Magdala Avenue London N19 5NF Barnet, Enfield and Haringey Mental Health NHS Trust Orchard House St Ann’s Hospital St Ann’s Road, London N15 3TH Camden & Islington NHS FT St Pancras Way London NW1 OPE Chief.executive@candi.nhs.uk 24 July 2017 Coroner ME Hassell Senior Coroner Inner North London St Pancras Coroner’s Court Camley Street London N1C 4PP Dear Coroner Hassell Prevention of future deaths report – Dominic Michael White We write further to your prevention of future death report dated 24 May 2017. Following the inquest, you recorded two matters which gave you cause for concern with regards the care provided to Dominic White. The first matter (level of mental health observations) spans Whittington Health NHS Trust, Camden & Islington NHS Foundation Trust, and Barnet, Enfield and Haringey Mental Health NHS Trust. This response, therefore, is a joint response from all three organisations addressing the concerns you have raised. The second matter concerns the decision making of the Approved Mental Health Professional. The AMHP is employed by the London Borough of Islington. When AMHPs are carrying out their duties, they act on behalf of the Local Authority. The London Borough of Islington will therefore provide you with a separate response to this issue. Mental health observations During the inquest you heard that following Mr White’s death, the level of mental health observations of a patient at the Whittington Hospital Emergency Department is clearly documented. However, you are not sure whether there is yet a robust protocol in place to ensure that all relevant personnel (Whittington ED doctors, nurses and security officers; and visiting independent s12 doctors, Barnet, Enfield and Haringey staff and Camden & Islington staff) are aware of the agreed level of observation. You have recorded your concern that sometimes, when anyone can look at a record, nobody actually does. 1 Protocol for implementing observation levels for mental health patients We set out below our agreed approach for ensuring that all relevant personnel are aware of a mental health patient’s level of observation. In order to address both concerns identified in the PFD, the Whittington and Camden & Islington have reviewed their mental health policies. These are being updated to ensure the roles and responsibilities are explicit and will also include case studies to assist in decision making. This will be included in Camden & Islington NHS Foundation Trust’s Mental Health Liaison Operational Policy and the Whittington Health NHS policy for mental health patients in the Emergency Department which is currently being updated. 1. Camden and Islington Foundation Trust’s mental health liaison team is responsible for recommending what the level of observations should be and for documenting this in the mental health care plan; 2. The mental health liaison team is responsible for informing the nurse in charge of Whittington Hospital’s ED and the named nurse looking after the patient in the ED what the recommended level of observation is; 3. The nurse in charge of ED and the mental health liaison team are jointly responsible for ensuring that security staff and any other relevant Whittington ED staff are fully aware of the required observation level; 4. Whittington Hospital’s ED staff are responsible for ensuring that the patient is observed in line with the observation level as documented in the mental health care plan; 5. Visiting AHMPs and section 12 doctors must introduce themselves to the nurse in charge of ED and the named nurse responsible for the patient and request a clinical handover (Including the current observation level) and to view the mental health care plan. Whittington Health ED Nurse in Charge and named nurse are responsible for facilitating this. 6. As part of improving communication between organisations signage has been introduced in Whittington ED, which is prominently placed around the nurses’ station, to ensure that visiting doctors and AHMPs are aware of this process and that the name of the patient’s allocated nurse and any 1:1 or ‘special’ staff member is visible outside the patient’s cubicle (see images). 7. To support patients in ED staffing levels have been increased to allow for an additional ED Assistant on each shift to provide support and 1:1 for mental health patients if required. All ED Assistants have been provided with additional training in mental health including communication skills, how to manage a difficult situation and Level 3 Breakaway training. 8. To ensure that the level of observations is being complied with and that the clinical decision making regarding Mental Health patients is robust Senior Whittington ED staff members (nurse in charge, site team, ED registrar or consultant) conduct a situation report 5 times per day in which the status of the department including 2 length of stay of mental health patients and risk assessment is discussed, this is followed by a review in which plans for patients are confirmed and quality of care is checked. In addition to the actions taken as part of the response to the prevention of future deaths report the following actions have also been undertaken: 9. A learning event based around this incident took place on the 15th June 2017 with 43 attendees from all three organisations. Discussions were held around joint working and staff members wrote personal pledges which were shared with the family. As a result of this, the Islington AHMP team has been invited to attend Whittington ED for a training session with ED staff so both teams can learn from each other. 10. The Emergency Care Improvement Programme has conducted a ‘deep dive’ into mental health care of patients presenting with mental health concerns at Whittington Health and in the local area. The results of this review will enable development of a plan for improvements in this area and how to support the trust(s) to achieve these improvements 11. In addition as part of the Emergency Care Improvement Programme a joint audit of a number of patients presenting to ED with mental health issues will be undertaken. Further improvements will be made in line with recommendations resulting from the deep dive. 12. Whittington Health has commissioned an independent review of the cluster of serious incidents relating to mental health, which will commence in July 2017. We hope that our joint protocol as set out above provides assurance as to how seriously we are taking the concerns you raised, and our ongoing determination, and commitment to ensure that we keep all our patients safe. Yours sincerely Simon Pleydell Chief Executive Whittington Health Maria Kane Chief Executive Barnet, Enfield & Haringey Mental Health Trust Angela McNab Chief Executive C&I NHS Foundation Trust 3
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