Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0229, written 7 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 | 7 Sep 2017 |
|---|---|
| Reference | 2017-0229 |
| Deceased | David Sewell |
| Coroner | Andrew Barkley |
| Coroner area | South Wales Central |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| 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. Chief Executive of Cwm Taff University Health Board 2. Head of Mental Health at Cwm Taff University Health Board CORONER | am Andrew Roger Barkley, Senior Coroner, for the coroner area of South Wales Central Area. 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. INVESTIGATION and INQUEST On the 13! June 2017 | commenced an investigation into the death of the David Michael Sewell aged 46. The investigation concluded at the end of an inquest today 6” September 2017. The medical cause of death was 1a. Transection of the left brachial artery and the conclusion of the inquest was “Suicide”. CIRCUMSTANCES OF THE DEATH The deceased lived on his own and was discovered in the bath at his address in the early hours of the 5" June 2017 by his mother who forced entry to his property. He was found covered in blood with obvious injuries to his arms. He was holding a cut throat shaving razor close to his face with his right hand. He was known to have suffered some form of a breakdown in July and August of 2016 after which he attempted to cut his arms and neck and was admitted to hospital. Upon his release he was under the care of the home treatment team who visited him daily from the 9" to the 14! July. He was reviewed by a Psychiatrist on the 13 July and prescribed medication. He was then re-admitted to hospital on the 24 August following a mixed overdose and was referred on to see a Psychiatrist within the Community Mental Health Team. He was not seen by a Psychiatrist as planned due to difficulties with appointments. His only other contact with health professionals were with his General Practitioner. 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) When Mr Sewell attended for the appointment with the Psychiatrist he was told by the main reception that they were unaware of a Health Worker of that name and he left the building. He was contacted by telephone on 3 occasions on the 16" and 17" August but displayed hostility towards members of the team. His case was discussed by the Multi-Disciplinary Team on the 18” August 2016 who decided to write a letter him which was sent on the 26" August inviting him to make contact or otherwise he would be discharged from the Teams care. He did not respond to that letter and no further follow up was made. The concern the evidence revealed relates to the apparent lack of a robust system to ensure that individuals with mental health problems, who may have experienced psychotic episodes as Mr Sewell had, are seen and appropriate care delivered. It was apparent from the evidence that after the letter was sent inviting him to make contact he was simply discharged from the case load with no further efforts or steps being made to try and re-engage him. There was clearly a need to do so. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you and 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 2"? October 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, the family and the Minister of Health Welsh Government Assembly 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. 7" September 2017
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.
Your reffeich cyf: Q G IG Bwrdd lechyd Prifysgo! Our reffein cyt: AW/KIF/INQ ay) CYMRU | Cwm Taf Date/Dyddiad: 9™ November 2017 Tos Tel/ffon: 01443 744800 HS University Health Board Fax/ffacs: W waces | vest ac 01443 744889 Email/ebost: Dept/adran: Patient Care & Safety Private & Confidential Mr Andrew Barkley Her Majesty’s Coroner Coroner’s Court Rock Grounds Aberdare CF44 7AE Dear Mr Barkley Re: Regulation 28 Report ~ David Michael Sewell Further the Regulation 28 Report received on the 7" September 2017 with regards to the above may I present our response to the matters raised. The Mental Health Directorate Management Team have reviewed the case and the circumstances of Mr Sewell’s engagement. As you state a referral was received at the Community Mental health Team (CMHT) following assessment by the Psychiatric Liaison Service. The referral was sent to the CMHT following a detailed assessment. on the 4 August 2017 that included consideration for detention under the Mental Health Act (MHA, 1983) which stated that Mr Sewell would not be detainable. It was therefore the professional view of the CMHT that this was not an option at the time of the presenting condition and that community services were deemed the appropriate course of action. It is clear from the clinical records and the staff involved that the referral was received, and the case allocated, in a timely manner. The view of the CMHT was that the issue became one of engagement, exacerbated by the fact that the initial appointment resulted in confusion as to where Mr Sewell should attend. This confusion arose as the CMHT had spoken with Mr Sewell and arranged for him to attend to meet with the allocated member of staff that would undertake the assessment at Ysbyty Cwm Cynon. This assessment would start the Care and Treatment Plan (CTP) process that would include the allocation of a Care Coordinator. However Mr Sewell attended at the main reception in Ysbyty_Q in.instead of the reception in the Mental Health department. As he wag n ay Return Address: Cwm Taf University Health Board, Headquarters, Navigation Park, Abercynon, CF45 4SN Chair / Cadeirydd, Professor Marcus Longley Chief Executive / Prif Weithredydd: Mrs A Williams Cwm Taf University Health Board is the operalional name of the Cwm Taf University Health Board/Bwrdd lechyd Prifysgol Cwm Taf yw enw gweithredol Your reffeich cyf: \ G IG Bwrdd lechyd Prifysgol Our ref/ein cyf. AW/KIF/INQ > OYMRU | Cwm Tat Date/Dyddiad: 9” November 2017 H oe Tel/ffn: 01443 744800 University Health Board ——_Fax/ffacs: 01443 744889 WALES Email/ebost: Dep¥fadran: Patient Care & Safety general systems for an appointment he subsequently left the hospital and was not seen. Further attempts to meet were met with hostility. To reduce this potential for confusion in the future the Adult Mental Health Directorate management teams have written to colleagues who are responsible for staffing the main reception (and their managers). Within this letter it reminds staff that people arriving for appointments that are not on the main system should be asked if the appointment is with the Mental Heath Team and if so direct accordingly. Also to be alert to the fact that people may be confused on the matter and require more attention. (letter attached). A review of the Disengagement Policy for Mental Health has been conducted, and it concluded that all stages of the policy were followed and it was reasonable at this time to discharge Mr Sewell as he clearly had no intention to meaningfully engage with the service. As consideration for Mental Health Act detention had been considered, the team wrote to Mr Sewell at the time as telephone contact was clearly antagonising the situation, to further offer a service. On reflection the team felt that having had contact with the Crisis Service previously, any future difficulties experienced by Mr Sewell would have led him to contact these services either directly or through referral by his GP. Unfortunately his death 10 months later was not preceded with any such contact. The Adult Mental Health Directorate have therefore concluded that it acted proportionately to the need presented at the time and in keeping with the Community Mental Health Act Disengagement Policy (enclosed). The possible requirement for using a MHA detention order was considered in Mr Sewell's assessment dated 4th August 2016. The Adult Mental Health Directorate also conclude that there was no further actions that we could have undertaken to engage with Mr Sewell, however, accept that procedures at the reception for engagement when discharged patients arrive unannounced or without an appointment require improvement. Yours sincerely Mrs llison Williams Chief Executive Officer Retum Address: Cwm Taf University Health Board, Headquarters, Navigation Park, Abercynon, CF45 4SN Chair / Cadeirydd; Professor Marcus Longley Chief Executive / Prif Weithredydd: Mrs A Williams Cwm Taf University Health Board ts the operational name of the Cwm Taf University Health Board/ Bwrdd lechyd Prifysgol Cwm Tal yw enw gweithredo!
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