Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0196, written 16 Jun 2017. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 16 Jun 2017 |
|---|---|
| Reference | 2017-0196 |
| Deceased | Lee Swain |
| Coroner | Anita Bhardwaj |
| Coroner area | Liverpool and Wirral |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Mersey Care NHS Foundation Trust · Cheshire and Wirral Partnership NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
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. Joe Rafferty – Chief Executive
Mersey Care NHS Foundation Trust, V7 Building, Kings Business Park,
Prescot, Liverpool, L34 1PJ
2.
– Senior Manager
Cheshire Wirral Partnership, Countess of Chester Hospital NHS Trust,
Countess of Chester Health Park, Liverpool Road, Chester, CH2 1UL
1
CORONER
I am Anita Bhardwaj, Area Coroner, for the area of Liverpool & Wirral
2
CORONER’S LEGAL POWERS
I 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
On 07/12/2016 I commenced an investigation into the death of Lee Joseph HASTINGS
SWAIN, Aged 28. The investigation concluded at the end of the inquest on 16/06/2017.
The medical cause of death was:
Ia Hanging
The conclusion of the inquest was:
Lee Joseph Hastings Swain took his own life whilst the balance of his mind was
disturbed.
4
Lee Joseph Hastings-Swain was a 28 year old gentleman who suffered from
Schizoaffective disorder and had been diagnosed with psychosis approximately 10-12
years ago for which he was prescribed Olanzapine and had received depot injections
over the years. Lee was under Sefton mental health team (Mersey Care NHS Trust
Foundation) and more recently Wirral Mental Health Team (Cheshire and Wirral
Partnership NHS Trust). On 30 November 2016 Lee was found deceased hanging from
the bannister at his home using a bed sheet. On the bed Lee had left an undated
handwritten note suggestive of the fact he was suffering from severe emotional
difficulties. Toxicology analysis showed nothing of significance which caused or
contributed to Lee’s death. It is unclear as to what Lee’s intentions were when carrying
out the act of self-harm but it is clear that he was suffering from mental health related
symptoms and so his mind was disturbed. Lee had been under the care of Mersey Care
NHS foundation since July 2005. During the years Lee’s engagement was sporadic and
he was placed on a Care Programme Approach(CPA), however subsequently he was
taken off the programme on the basis of other clinical regular appointments. In March
2016 Lee moved to Wirral and Mersey Care discharged Lee from their services and
referred him to Cheshire Wirral Partnership (CWP) via the General Practitioner (GP). In
May 2016 The Wirral GP referred Lee to the CWP who failed to make contact with Lee
1
and an assessment never took place. Within the Mental Health Services, the following
failures occurred in the care and treatment of Lee: Mersey Care inappropriately removed
him from the CPA when he clearly needed the continuity and engagement; Lee’s care
was not co-ordinated across services. Referrals through the GP were made rather than
a transfer from service to service. If Lee had remained under the CPA the transfer would
have been more effective – service to service; Despite Knowing that Lee was moving to
the Wirral in March 2016 a referral letter with the clinical history was not sent until June
2016 which was an unacceptable delay; Cheshire Wirral Partnership Mental Health
Services’ Staff failed to adhere to Operational procedures in that the clinical notes were
poor and inadequate. The notes were brief and did not fully detail decisions made or
rationale for those decisions; CWP engagement with Lee fell short of expected
standards, essentially comprising of appointment letters to his home address. The
pattern of non-attendance should have triggered a more pro-active response to engage
Lee with the service. There were a number of failures by the mental health services. It is
unclear as to whether a more effective transfer from one service to another and thus
earlier and more pro-active intervention would have changed the outcome for Lee,
however, there were clear missed opportunities for further intervention to help and
support Lee. A more co-ordinated approach from the mental health services may have
given better opportunities to engage Lee so that he could have received the support and
treatment he so desperately needed.
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. –
A more co-ordinated approach from the mental health services is required when a user
is being transferred from one NHS Trust to another. In this case if the user had still been
on a Care Programme Approach there would have been a direct referral from service to
service rather than through the GP but because he was taken off the programme the
referral was made through the GP. This has delayed the intervention and the prevented
effective information exchange on a user who was already subject to secondary care
services. In effect this resulted in the user having no intervention for a number of months
and entering the mental health system afresh when in fact the care should have been a
seamless continuation.
The Court would like you the Current Transfer / Referral Policy.
6
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe 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 14/08/2017. 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 Chief Coroner and to the following Interested
2
Persons:
1.
2.
s – mother
- father
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 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.
9
Anita Bhardwaj
Area Coroner for the
Liverpool & Wirral Coroner Area
Dated: 16th June 2017
3
'~l:kj Mersey Care NHS Foundation Trust Patient Safety Team Mersey Care NHS Foundation Trust Offices V7 Building Kings Business Park Prescot Merseyside L34 1 PJ Telephone number: 01514732874 14 August 2017 PRIVATE & CONFIDENTIAL Area Coroner for the Liverpool and Wirral Area Anita Bhardwaj Gerard Majella Courthouse Boundary Street Liverpool L52QD Dear Madam Re: lee Joseph Hastings Swain - Inquest I write further to the Inquest into the death of Mr Hastings Swain which concluded on 16 June 2017. At that Inquest you expressed the following concerns: A more co-ordinated approach from the mental health services is required when a user is being transferred from one NHS Trust to another. In this case if the user had still been on a Care Programme Approach there would have been a direct referral from service to service rather than through the GP but because he was taken off the programme the referral was made through the GP. This has delayed the intervention and the prevented effective information exchange on a user who was already subject to secondary care services. In effect this resulted in the user having no intervention for a number of months and entering the mental health system afresh when in fact the care should have been a seamless continuation. The Court would like you to review the Current Transfer I Referral Policy. The Trust is grateful to you for the opportunity to update you as to the progress made to implement these measures since the conclusion of the Inquest and I now write to provide that update. Trust responses The two Trusts involved namely Cheshire and Wirral Partnership NHS Foundation Trust (CWP) and Mersey Care NHS Foundation Trust (MCFT) met to discuss the responses to your concerns and agreed that both organisations would review their policies separately but ensure that the guiding principle of making it clear to staff the processes that should be adopted when transferring patients from one organisation to another was undertaken as part of this review. It was felt to be important to Mersey Care NHS Trust is a smoke free NHS Trust and operates a smoke free policy. Please note that smoking is not permitted on any of our sites including buildings. grounds. and car parks. Smoking is not permitted at the entrances or exits of buildings and sites. undertake separate reviews of Trust policies as they have to be representative of specific dynamics and structures within the organisations and the different organisations that patients may be transferred to locally. That said I can confirm that both organisations have shared their respective policies and agreed inclusions to both that are reflective of the Regulation 28 report. Cheshire and Wirral Partnership NHS Foundation Trust (CWP) response CWP has identified that the following statements in relation to the timeframe for transfer of care should be included in its policy 'Admission, Discharge and Transfer of Care Policy' as additional practice guidance for staff. The additional statements read:- "This will be completed within a timeframe of 28 days but may have to be expedited if there are concerns about the person's risk profile and mental health." "The referral will go to the single point of access service of the relevant receiving trust. " An action plan has been developed and includes the Trust's own findings from its investigation in relation to documentation and record keeping which fell short of the Trust's expectations. The updated policy and action plan will be approved at the Trust's Quality Committee on 6 September 2017 and will detail the timetable for each individual action, which will again be monitored by the Quality Committee. Learning will be shared Trustwide through the Learning from Experience Report in September 2017 and through the locality governance structures. Mersev Care NHS Foundation Trust (MCFT) response I have enclosed the key changes that have been made to policy following the Regulation 28 report at Appendix 1. I can confirm that the outcome of the inquest hearing and the required changes to the policy have been circulated within MCFT through operational management meetings, consultant forums and via Quality Practice Alert (QPA). I can also confirm that the QPA was issued prior to the Inquest hearing on 16th March 2017 as part of the Trust's processes of learning from this incident. This included clear guidance on what is expected of teams when a patient is being transferred from one organisation to another. The contents of the QPA included -: "The importance of timely and comprehensive handover of information, both verbal and written when transferring service users from one care team to another cannot be overstated and underpins the guidance above. This applies to CPA and non CPA service users." The inclusion of the above statements will ensure that CWP and MCFT, (once both Trust's amendments have completed their respective governance ratification processes) have policies that are compatible. I can also confirm that the respective CWP and MCFT teams involved have also had specific feedback. An audit of transfer processes based on the amended policies will be considered for inclusion in each Trust's Junior Doctor Audit programme. I hope that this response adequately addresses the concerns you have raised, however please do not hesitate to contact me if I can provide further clarification. Mersey Care NHS Trust is a smoke free NHS Trust and operates a smoke free policy. Please note that smoking is not permitted on any of our sites including buildings, grounds, and car parks. Smoking is not permitted at the entrances or exits of buildings and sites. Director of Patient Safety Mersey Care NHS Trust is a smoke free NHS Trust and operates a smoke free policy. Please note that smoking is not permitted on any of our sites including buildings, grounds, and car parks. Smoking is not permitted at the entrances or exits of buildings and sites.
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