Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0288, written 8 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 | 8 Aug 2017 |
|---|---|
| Reference | 2017-0288 |
| Deceased | Fallon Abby |
| Coroner | Mary Hassell |
| Coroner area | Inner North London |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths · Community health care and emergency services related deaths · Suicide (from 2015) |
| Organisation named | East London 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
Fallon Alphonsine ABBY (died 19.02.17)
THIS REPORT IS BEING SENT TO:
1. Dr Kevin Cleary
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 19 February 2002, one of my assistant coroners, Heather Williams,
commenced an investigation into the death of Fallon Abby, aged 18
years. The investigation concluded at the end of the inquest on 7 August
2017.
I made a determination of suicide, when Fallon jumped from the balcony
of her sixth floor bedroom at around 10.45pm on Saturday, 18 February
2017, while two members of the ambulance service were attempting to
persuade her to go to hospital for treatment.
4
CIRCUMSTANCES OF THE DEATH
1
Fallon had attended the emergency unit at the Royal London Hospital a
week before her death following an intentional overdose, then re-
presented with alcohol toxicity. She was admitted to Roman Ward of
Mile End Hospital because she was thought to be at high risk of suicide.
She was discharged to the care of the home treatment team on
Thursday, 16 February 2017.
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.
I heard at inquest that no member of the team on Roman Ward contacted
Fallon’s social worker. There was no protocol for this.
If they had sought a collateral history from the social worker, they would
have discovered that Fallon’s mum was not dead as Fallon had told
them, but was alive and living in a hostel. The social worker had been
rung by a nurse at the Royal London Hospital, but she was waiting to be
invited to a ward round at Mile End Hospital and such invitation was
never made.
It seems unlikely that proper discussion with the social worker would
have changed the outcome for Fallon, but it would have meant that
valuable information would have been shared, and it would have meant
that Fallon would have had the benefit of her social worker on hand upon
discharge. This might be very important for another patient.
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 9 October 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.
2
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
Care Quality Commission for England
, sister of Fallon Abby
, sister of Fallon Abby
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
08.08.17
3
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.
East London INHS NHS Foundation Trust Please respond to: Associate Director of = = Trust Headquarters 9 Alie Street London E1 8DE Telephone: 020 3738 7253 9" October 2017 Senior Coroner M E Hassell Inner North London Poplar Coroner’s Court 127 Poplar High Street London E14 0AE Dear Madam Inquest touching upon the death of Fallon Abby This is a formal response to your Regulation 28 Report dated 8" August in which you set out your concerns relating to the care Miss Abby received from East London NHS Foundation Trust. | am aware that you heard evidence at the Inquest that Miss Abby had a social worker from the Leaving Care Team. You were concerned that during Miss Abby's admission to the Ward no contact was made with the social worker and no invitation was issued for her to attend the ward round. Miss Abby's case highlighted that there was a lack of knowledge regarding the involvement of the Leaving Care Team, with ward staff being unaware that a young adult leaving care would have an allocated social worker up until the age of 25. Therefore, whilst Miss Abby's social worker had been informed of her assessment by the psychiatric liaison team in the Emergency Department she was not contacted by ward staff, invited to the ward round of informed of her discharge from the ward. In order to address this a number of actions will be undertaken as follows: Firstly, the Named Professional for Safeguarding Children will ensure that Safeguarding Children Training, which is mandatory for all staff, will include information about the Leaving Care Team and their involvement with a young person up to the age of 25. Po Chief Executive: Dr Navina Evans The Named Professional for Safeguarding Children will also undertake some bespoke training with Ward managers and Matrons in relation to this specific issue for cascading to all ward staff. This case and the issues highlighted will also be discussed at the regular Consultant’s meeting and again cascaded to junior staff. In addition the Operational Policy for the ward will be reviewed to include the requirement to contact the Leaving Care Team in the event of an admission of a young person who has previously been in care. Once the Leaving Care Team has been informed of an admission staff will work with the young person to negotiate the involvement of their social worker. With the changes planned | hope you will be content that the Trust has taken these issues seriously and adequately addressed your concerns. If you do require any further information please do not hesitate to contact me. Yours faithfull eputy Medicat Director ior and ehalf of ting Chief Medical Officer Po Chief Executive: Dr Navina Evans
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