Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0248, written 21 Aug 2017. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 21 Aug 2017 |
|---|---|
| Reference | 2017-0248 |
| Deceased | Francesca Whyatt |
| Coroner | Karon Monaghan |
| Coroner area | London Inner (West) |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| 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: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. CARE QUALITY COMMISSION 2. NATIONAL HEALTH SERVICE ENGLAND 3. CHAIR AND MEMBERS OF MENTAL HEALTH NATIONAL PROGRAMMES OF CARE BOARD, NATIONAL HEALTH SERVICE ENGLAND 4. HOSPITAL DIRECTOR, PRIORY HOSPITAL, ROEHAMPTON 1 CORONER I am Karon Monaghan QC, Assistant Coroner, for the coroner area of London Inner West. 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 On 30th September 2013 an investigation was commenced into the death of Francesca Whyatt (date of birth 18th September 1992) and concluded at the end of the Inquest on 4th August 2017. The Jury came to a narrative conclusion. Their conclusion included findings that: (1) The protocols, procedures and risk assessments were not updated to reflect the challenges and changes to the Emerald Ward. The layout of the ward over four floors and the system of fob and key doors made the policy unworkable with the level of staff provided. (2) The zonal observation policy failed and staff were unaware of how it operated. (3) Prohibited items of ligature were not strictly monitored or controlled. (4) On the day of the incident there was a complete lack of leadership, there were very few experienced staff on duty, several were new or with only days of experience on the ward. (5) The training and induction of staff was generic and not fully suited to the particular requirements at the Emerald Ward. The reliance on agency staff added to the risk and detracted from the continuity and effectiveness of the therapy of the ward. More could have been done earlier to recruit permanent staff. (6) Francesca Whyatt’s death was contributed to by neglect in that she was permitted to wear tights. (7) Francesca Whyatt’s death was contributed to by neglect in that she was able to ascend from the garden to the first floor unrestricted by a locked door and/or staff intervention. (8) Francesca Whyatt’s death was contributed to by neglect in that there were no zonal or intermittent observations undertaken between the period 4.05 p.m. – 4.20p.m.. 1 4 CIRCUMSTANCES OF THE DEATH Francesca Whyatt was admitted to the Priory Hospital, Roehampton on 20th March 2013 under section 3, Mental health Act 1983, to its specialist Personality Disorder Unit, East Wing (thereafter known as “Emerald Ward”). The unit provided NHS commissioned services to patients requiring specialist care from all over England and Wales. Many of the patients in the Emerald Ward were at high risk of serious self-harm and all required complex and expert care. Emerald Ward was arranged over four floors (basement, ground, first and second), each separated by a single staircase. Observations of patients were primarily carried out “zonally” so that a member of staff was allocated to each floor to observe patients, save that in the case of the first and second floor, a single member of staff was allocated to undertake observations on both floors. In addition, patients were sometimes subject to closer observations (intermittent, 1:1, 2:1) where heightened risk was identified. The doors between the basement, ground and first floor were expected to be locked at all times with access granted to patients by a member of staff using a “fob” key. There was no locked door between the first and second floors. Francesca Whyatt was at known risk from ligatures. A risk assessment (“risk management self-harm plan”) was prepared shortly after her admission to the Emerald Ward indicating that she should not have tights or belts. This was because it was understood that she was more likely to self-harm with these items. On 16th April and 17th June 2013, Francesca Whyatt gained access to tights and fashioned ligatures out of them and tied them around her neck. On 6th August 2013 Francesca Whyatt used a belt cord from a dressing gown to which she had been provided access, and tied it tightly around her neck. She was discovered cyanosed and with a nosebleed. This was recognized to be a “near - miss”. This incident at least should have been treated as a serious untoward incident (SUI) and as such a formal SUI investigation should have been undertaken. The Incident Form that was used to report the incident described the level of harm as “low” and no investigation took place. On 25th September 2013 at a time between 4.05 p.m. and 4.20p.m., Francesca Whyatt was able to ascend from the basement to the top floor, through doors which were unlocked though expected to be locked, without being observed. She was then found unconscious in a lounge on the top floor of the Emerald Ward with a pair of tights around her neck secured tightly as a ligature. Attempts were made to resuscitate her at the scene. She was then taken to Kingston Hospital where she died on 28th September 2013. The medical cause of Fancesca Whyatt’s death was: 1a. Irreversible cerebral anoxia 2b. Upper airway obstruction Emerald Ward closed in June/July 2014. East Wing is now a 12 - bedded female acute mental health ward with the majority of patients diagnosed with psychosis and some are at high risk of self-harm. The NHS funds the care and treatment of the majority of the patients on East Wing through commissioning arrangements. East Wing remains a single ward arranged over four floors, with one floor now inaccessible to patients without supervision. There are no locked doors impeding access to and up the staircases between floors. There has been no risk assessment of 2 the configuration of the ward over four floors. Agency staff are still used (though in much fewer numbers). They must complete an observation competency checklist when they commence work on the ward. There is no written or other formal guidance on the frequency with which ad-hoc agency staff must complete the checklist. Ligature incidents are not automatically treated as SUIs. There is no clear guidance or criteria on the circumstances in which a ligature incident/s (or other self-harming incident/s) should be treated as an SUI such as to trigger an SUI investigation. 5 CORONER’S CONCERNS During the course of the Inquest, my inquiries 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) There has been no risk assessment of the configuration of the East Wing ward over four floors. (2) There is no written or other formal guidance on the frequency with which ad-hoc agency staff should complete the observation competency checklist. (3) Ligature incidents are not automatically treated as SUIs (though the evidence suggests that death can occur within seconds of a ligature being applied). (4) There is no clear guidance or criteria on the circumstances in which a ligature incident/s (or other self-harming incident/s) should be treated as an SUI such as to trigger an SUI investigation. 6 ACTION SHOULD BE TAKEN In my opinion urgent action should be taken to prevent future deaths and I believe you and your organisation have the power to take such action. It for each of the individuals or agencies to whom this report is addressed to identify any specific and appropriate action that should be taken on their or their organisation’s behalf in relation to the concerns listed above. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 16th October 2017. I, the Assistant 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 Persons: (1) The Family of Francesca Whyatt (2) The Priory Hospital, Roehampton (3) (4) The Health and Safety Executive 3 (5) The Metropolitan Police Service (6) (7) (8) (9) 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 21st August 2017 Karon Monaghan QC Assistant Coroner, Inner West London 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.
TRE PRIORY HOSPITAL ROEHAMPTON Ms Karon Monaghan Qc Assistant Coroner Inner West London 65 Horseferry Road London swiP 2ED Strictly Private & Confidential 42" October 2017 Dear Ms Monaghan, Re. Ms Francesca Whyatt (deceased) I write to you in response to the Regulation 28 Report to Prevent Future Deaths dated Monday 21 August 2017 that you issued in response to the Inquest Touching the Death of Ms Francesca Whyatt. The matters of concern and responses are set out below. There has been no risk assessment of the configuration of the East Wing ward over four floors. As a preliminary issue, I would respectfully ask you to please note that patients are unable to access the rooms on Floor 4 or the whole of the basement (Floor 1) without being escorted. Further, I would wish to make the general point that many units in the UK for patients with mental health issues are multi-level and that ward layout will inform the main risk assessment and management tool i.e. the clinical risk assessment for a patient. In addition, to support clinical risk assessments, there will be more general environmental and health and safety risk assessments which are summarised below. Clinical Risk assessments: All ward patients have a current clinical risk assessment and management plan in place. In order to meet the requirements of these assessments and plans, on a day-to-day basis the ward has a regular core staff team in place with oversight from an experienced ward manager and hospital management team. Systems are in place to ensure that the patient group are subject to co-ordinated safety observations undertaken by a fully trained staff team. All observations are undertaken in accordance with Policy H43 Observation and Engagement. Tt should also be noted that during the day, the patients are occupied in individual therapy and group work and will therefore occupy particular areas of the ward (or other areas of the Hospital) in the presence of staff. Environmental risk assessments: prior to the opening of a service and on an ongoing basis, there will be an environmental risk assessment which will include ligature point and blind spot audits. These audits will be refreshed at least twice a year. Additionally there are weekly Quality Walk Rounds completed by senior nursing staff - these include reference to patient and staff safety and make reference to corridors being kept free of obstruction, areas that present as a risk being effectively managed and emergency equipment being available. The completed documents are THE PRTORY reviewed by the relevant hospital director and are also subject to a review by the aetna MPTON divisional quality team. Health and_safety risk assessments: these will include the Potential Violence Risk Assessment (which has recently been updated and scrutinised by our Director of Risk and Safety who has found the assessment to be accurate and suitable). The assessment document is completed prior to any new ward opening and also in response to any serious incident of violence and aggression or significant change in patient profile. The assessment assists staff in identifying any actions that need to be taken to assist in reducing the likelihood of a violent incident. Additional health and safety risk assessments and audits that assist in ensuring patient and staff safety include fire risk assessments, infection control and anti-barricade door audits. There is no written or other formal guidance on the frequency with which ad-hoc agency staff should complete the observation competency checklist. We would wish to make the general point that ward staff will have access to agency staff training records on an ongoing basis to enable a check to be made of when the observation competency for a particular member of staff was last completed. However, we can see the benefits of this practice being codified in our existing Policy H43 Observation and Engagement and the following requirement has now been added: ‘Where a bank or agency member of staff has a break in service of over one month then H Form: 99 Observation Competency Checklist must be completed again’. This additional requirement will be communicated to divisional staff during week commencing Monday 16 October 2017 via the weekly divisional newsletter and as part of the ongoing observation and engagement staff training webinars that are delivered on a monthly basis. Ligature incidents are not automatically treated as SUIs (though the evidence suggests that death can occur within seconds of a ligature being applied). We would wish to make the general point that self-harm incidents both generally and those involving a ligature will vary in their nature and degree and it would not be appropriate for all ligature incidents to be treated as SUIs. It will depend on the patient and the particular circumstances in each case. Accordingly, it is for the staff who deal with the incident on the ward to make a determination, in particular the ward manager, as to how such an incident should be graded. However, all ligature incidents will be recorded on our e-compliance system within 48 hours of the incident and all e-compliance incident reports are reviewed by the hospital management team within 72 hours of the incident report being made: they will check the accuracy of the report and the incident grading. Where necessary the incident grade will be amended. Incident reports are also reviewed on a daily basis by the central risk and audit team and where appropriate, there will be follow-ups with the Hospital to check on how the incident is being managed and what changes to a patient's risk assessment are needed. More serious ligature incidents resulting in medical intervention will be the subject of a detailed serious incident report (called an SBAR) which will be sent to the central risk and audit team and escalated to the senior levels of management for review with an SUI report being commissioned in appropriate circumstances. Again, though this happens in practice, we can see the benefits of this THE PRIORY being expressly set out in our Incident Management, Reporting and Investigation ROL AMPTON Policy (OP4) and the following requirement has been added to the policy: "Serious self-harm incidents involving a ligature or self-mutilation of such severity that the service user was at risk of death and/or life changing injuries and which necessitated medical treatment” will require an SBAR notification to be made and a further investigation will be commissioned to enable an understanding of the actual incident and identification of any improvements that need to be made to assist in preventing a repeat of similar incidents in the future. This requirement will be communicated to divisional staff during week commencing Monday 16 October 2017 via the weekly divisional newsletter. There is no clear guidance or criteria on the circumstances in which a ligature incident/incident/s or other self harming incident/s) should be treated as an SUI such as to trigger an SUI investigation. As with point 3 above, we have identified that any self-harm incident which requires medical attendance and medical intervention will be recorded as a serious incident and will require escalation with a serious incident investigation being commissioned by the divisional management team in appropriate circumstances. The report arising from that investigation will be shared and any lessons learnt and improvements will be rolled-out across the division as required. I do hope that these actions will provide you with the reassurance that you require. If I can be of further assistance then please do not hesitate to contact me. Yours sincerely, Hospital Director
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