Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0218, written 11 Sep 2017. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 11 Sep 2017 |
|---|---|
| Reference | 2017-0218 |
| Deceased | Janet Williams |
| Coroner | Mary Hassell |
| 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 | none published |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Regulation 28: Prevention of Future Deaths report
Janet WILLIAMS (died 08.03.17)
THIS REPORT IS BEING SENT TO:
1.
Medical Director
East London NHS Foundation Trust
Trust Headquarters
9 Alie Street
London E1 8DE
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
On 13 March 2017 I commenced an investigation into the death of Janet
Williams, aged 54 years. The investigation concluded at the end of the
inquest on 10 September 2017. I made a determination as follows.
Janet Williams’ death was the result of suicide. She hanged herself at
home whilst suffering late onset paranoid schizophrenia. This had
developed a little over a year before her death. During that time, despite
very significant efforts by family members, there was a healthcare
professional failure properly to monitor and therefore to assess and treat
Ms Williams appropriately.
4
CIRCUMSTANCES OF THE DEATH
1
Ms Williams became ill in early 2016 and was referred to mental health
services by her general practitioner. She was admitted to Brick Lane
Ward at the Tower Hamlets Centre for Mental Health on 9 March 2016
as a voluntary patient and discharged to the home treatment team on 8
April. She was under the care of the home treatment team until 29 April,
and then again from 16 September until 11 October 2016.
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.
1. Ms Williams’ care plan approach (CPA) was not recorded on the
computer system and so there were no automatic alerts
generated when she was not seen for review at the appropriate
times. The lack of computer record of her CPA was never noted.
2. Ms Williams told her care co-ordinator that she was no longer
hearing voices, but her daughter raised concerns that this was not
true. Ms Williams’ care co-ordinator did not at any point in April
2016 or afterwards raise this with Ms Williams, but instead
accepted Ms Williams’ narrative as accurate.
3. Ms Williams was not reviewed in accordance with the protocol for
a person on a CPA. A medical review with her consultant
psychiatrist scheduled for 12 May 2016 was cancelled by her care
co-ordinator. The reason given was that the psychiatrist was
unwell, though in fact she was not.
4. A meeting was then scheduled three months’ away, for 9 August
2016, despite the need for medical review and the lack of any
alternative arrangement in the meantime.
5. Between 11 October 2016 when Ms Williams was discharged by
the home treatment team, to 21 February 2017 when she saw her
general practitioner and her care co-ordinator together, Ms
Williams’ care co-ordinator did not meet with her.
6. Between 11 October 2016 when Ms Williams was discharged by
the home treatment team, and her death on 8 March 2017, Ms
Williams’ care co-ordinator did not arrange for a medical review
by the psychiatrist.
2
7. When Ms Williams’ family attempted to raise concerns with her
care co-ordinator, at times their calls were not returned and at
other times their concerns were simply not acted upon. She had
recently been diagnosed with a very serious mental health
condition, but she was not monitored with sufficient care or in
some instances at all, and she was therefore not assessed or
treated appropriately.
8. Finally, as I know you are aware, the care co-ordinator made
several retrospective entries in the medical records that she did
not record as being made retrospectively. These entries were
made up to eleven months after events, and were made after Ms
Williams’ death and mostly after my request for a statement from
the care co-ordinator in preparation for the inquest.
I attach to this report a copy of the report I made to you on 26 July 2017
concerning the death of Songul Bozdag. You will see that there are
themes common to both deaths.
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 6 November 2017. I, the coroner, may extend
the period.
As I have indicated, I wrote to you about similar matters on 26 July 2017
in respect of the death of Songul Bozdag on 9 February 2017. Given the
parallels, I hereby extend the period for your response to my earlier letter
from 26 September 2017 to 6 November 2017, so you may send both
responses at the same time.
Your responses 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 QC, the Chief Coroner of England & Wales
3
Care Quality Commission for England
The Health & Care Professions Council
, consultant psychiatrist
, care co-ordinator
, sister of Janet Williams
, London Borough of Tower Hamlets
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 Senior Coroner, at the time of your response,
about the release or the publication of your response by the Chief
Coroner.
9
DATE SIGNED BY SENIOR CORONER
11.09.17
4
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