Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0304, written 10 Oct 2017. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 10 Oct 2017 |
|---|---|
| Reference | 2017-0304 |
| Deceased | Christopher Kiernan |
| Coroner | Mark Beresford |
| Coroner area | South Yorkshire (East) |
| Category | Community health care and emergency services related deaths · Suicide (from 2015) |
| 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.
Mark Andrew Beresford Assistant Coroner for South Yorkshire (East District) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Mr Rod Barnes, The Chief Executive Yorkshire Ambulance Service, Springhill 2, Wakefield 41 Business Park, Brindley Way, Wakefield WF2 0XQ CORONER | am Mark Andrew Beresford, Assistant Coroner for South Yorkshire (East District) 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. http://www legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www. legislation.gov.uk/uksi/2013/1629/part/7/made INVESTIGATION and INQUEST On 05/06/2017 | commenced an investigation into the death of Christopher Cyril Kiernan, 52 . The investigation concluded at the end of the inquest on 10 October 2017. The conclusion of the inquest was Suicide. The cause of death was: 1(a) Suspension by ligature. CIRCUMSTANCES OF THE DEATH Mr Kiernan, who lived with his wife of 30 years, had a history of mental health issues. He had suffered from periods of depression. He had a habit of drinking alcohol. He also had some history of cannabis use. Indeed, metabolites of cannabis were found in his pre — mortem blood sample. Intoxicants tended to have a negative impact upon his mood. Mr Kiernan had had involvement with the local mental health services (RDaSH). He expressed, to his family, the view that he felt that no one was listening to him. He had expressed suicidal ideation to mental health practitioners but not recently to his family. Mr Kiernan’s mood was said to have worsened during the week or so prior to his death. He had become very withdrawn. On the evening of Saturday 3 June Mr Kiernan made an emergency call but then aborted the call without providing any information. In accordance with standard practice, the matter was forwarded to an emergency call handler who, at 22:19, succeeded in contacting and speaking to Mr Kiernan. The call handler found it very difficult to obtain information from Mr Kiernan. He was uncooperative and appeared to be intoxicated. However, he did make a threat to harm himself. The emergency call handler graded the call as “immediate” to ensure the prompt despatch of resources. Police officers arrived at Mr Kiernan’s home at around 22:30. They found that both Mr and ii Kiernan were present. P| was unaware that her husband had been in contact with the emergency services. She directed the Officers to Mr Kiernan’s bedroom. The Officers found Mr Kiernan holding a small hand axe. The officers instructed Mr Kiernan to put the axe on the floor. After several seconds he complied with the request and apologised saying that he did not know who was about to enter his bedroom. Mr Kiernan was slurring his words when he spoke to the officers. He smelled of alcohol and they formed the opinion that he was intoxicated. He told the officers that he was finding it hard to cope and that he was not getting any help regarding his issues. After several minutes, Mr Kiernan’s daughter arrived and began to console her father. Mr Kiernan summarised some Coroner's Court and Office, Doncaster Crown Court, College Road, Doncaster, DN1 3HS Tel 01302 737135 | Fax 01302 736365 background family issues that were causing him distress. Initially, he told the Officers that he felt like dying, due to these issues, but, after he had spoken to them for a while, Mr Kiernan stated that he needed help and wanted to speak to someone. He refused to attend hospital for assistance but did agree to speak to a mental health worker over the telephone. The Officers spoke to Mr Kiernan’s family members who agreed to look after Mr Kiernan. They left the property at about 23:00 hrs. They informed their force control that the ambulance that was en route should be cancelled but that they should arrange for “the mental health triage” to speak to Mr Kiernan that night by telephone. The emergency call handler’s service desk contacted the YAS triage nurse at 23:03. They did not contact the crisis team. At 23:12 the YAS triage nurse telephoned Mr Kiernan’s number. He /she spoke to Mr Kiernan’s daughter who informed him/her that the police had left. It appears that Mr Kiernan was too intoxicated and/or agitated to speak to the triage nurse. The triage nurse left, with Mr Kiernan’s daughter, the telephone number for the RDaSH crisis team. He/she did not speak to Mr Kiernan direct. Mr Kiernan’s daughter then left her parents’ home in order to return to her own home. She left the crisis team telephone number with her parents. On 5 separate occasions, between 00:14 and 01:39 on the early morning of Sunday 4" June 2017, Mr Kiernan, unbeknown to his wife, called the emergency services and spoke to emergency call handlers. During the conversations that took place, Mr Kiernan was generally abrasive in manner and difficult to understand. He indicated, on more than one occasion that he was awaiting the call from the crisis team. Notwithstanding a note that had been logged on their PROCAD system, the emergency call handlers appear to have assumed that the crisis team were going to contact Mr Kiernan and they advised him to clear the line so that he could receive any incoming call. Throughout this process, however, the crisis team had received no notification at all regarding Mr Kiernan. The PROCAD note referred to above read as follows:- “mental health nurse has made contact and made arrangements for the daughter to contact appropriate resources at patient's request. No further requirement for AMB. Thanks’. At around 06:45 on Sunday 4" June 2017, a despatcher noted that the incident relating to Mr Kiernan was still open. He contacted one of the officers who had attended the previous evening. That officer telephoned the home and spoke to Mrs Kiernan who assured him that her husband was asleep in bed. At about 11:00 that morning Mr Kiernan left the family home. Shortly afterwards he was found in an area of nearby woodland hanging from a tree. There was no direct contact between the mental health triage nurse and the crisis team at RDaSH. Accordingly, since the police officers and their force’s service desk appear to have assumed that Mr Kiernan’s crisis needs were being met, the RDaSH crisis team were not contacted by them. The YAS witness who gave evidence at the Inquest accepted that there appeared to be a general misunderstanding as to the role being played by the triage nurse. She stated that, had the officers being present when the triage nurse made contact, the triage nurse would/should have informed the officers that the YAS mental health service is not a crisis one. The YAS witness also said that, although the crisis team contact number was left with the daughter, there was a means by which the YAS Triage nurse could/should have contacted the RDaSH crisis team direct. The YAS witness also accepted that the circumstances in which the direct communication pathway between the YAS triage nurse and the RDaSH crisis team should be subject to consideration. Coroner's Court and Office, Doncaster Crown Court, College Road, Doncaster, DN1 3HS Tel 01302 737135 | Fax 01302 736365 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 MATTER OF CONCERN is as follows. — The ineffectiveness of the pathway for communicating information direct to the RDaSH Crisis Team. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you The Chief Executive has 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 Tuesday 5th December 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 and to the following Interested Persons: SES > MEINE: Viessrs Browne Jacobson | 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. Dated 10th October 2017 Signature ee Assistant Coroner for S shire (East District) Coroner's Court and Office, Doncaster Crown Court, College Road, Doncaster, DN1 3HS Tel 01302 737135 | Fax 01302 736365
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.
Yorkshire Ambulance Service NHS Trust 15 December 2017 Springhill 2 Brindley Way Wakefield 41 Business Park Wakefield WF2 0XQ Mr M A Beresford Tel: 0845 124 1241 Assistant Coroner for South Yorkshire (East District) Coroner’s Court and Office Crown Court College Road Doncaster DN1 3HS Dear Mr Beresford Inquest touching the death of Christopher Cyril Kiernan (Deceased) Response to Regulation 28 Report to Prevent Future Deaths dated 24 October 2017 | refer to your report dated 24 October 2017 issued under paragraph 7 Schedule 5 of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. | am aware that during the inquest hearing on 10 October 2017 in respect of Mr Kiernan you heard evidence relating to the function of Mental Health Nurses within Yorkshire Ambulance Service NHS Trust (“the Trust’) and as a result a Regulation 28 Report has been issued. The purpose of this letter is to provide you with a full response to the concern as set out in your report, in so far as this is an issue which can be addressed by the Trust. | set out your concern and seek to address it below. The ineffectiveness of the pathway for communicating information direct to the RDaSH Crisis Team The Trust provides 999 support for patients in crisis. This is achieved by a dedicated team of Mental Health Nurses within the Emergency Operations Centre (“EOC”) triaging incoming 999 calls where the chief complaint relates to mental health concerns. Based on the content of the call, and discussion with the patient where possible, the Mental Health Nurses identify whether an ambulance response to the patient is required to facilitate conveyance to an Emergency Department. MINDFUL ‘Ss www.yas.nhs.uk Sona § We In situations where it is deemed an ambulance response is not required the role of the Mental Health Nurse is to provide support to ensure the right care can be sought within the 999 call. The options available to the Mental Health Nurse during the call are: e signposting the patient to a crisis service by providing the contact information of the relevant service; e making a direct contact with Mental Health Services (with patient consent) for those patients who are already receiving care and support in the community; or e providing self-care advice (e.g. on a medication issue). Importantly, the EOC Mental Health Team is not a crisis team, unlike those operated by Mental Health Trusts. The function is limited to the actions above which can be undertaken throughout the 999 call. The Trust currently does not provide a callback or crisis service; once a call is terminated the Trust involvement ceases and the operative moves to the next awaiting 999 call. With regards to the Trust's contact with Mr Kiernan, once it was communicated by South Yorkshire Police communications centre (“SYP”) that an ambulance disposition was not required the call should have been closed from a Trust perspective, however this position was not clearly communicated or understood. The passing of responsibility by SYP to the Trust to initiate referral or signposting at this was stage was incorrect and outside the obligations of the Trust. At that point, the obligation to liaise with Mr Kiernan and any relevant service resided with SYP, and this should have been made clear in dialogue between the emergency services In this instance, the Trust operative in fact undertook a callback and provided signpost information. This deviated from process and potentially led to confusion as to whether or not a referral to a crisis team had been made. Addressing your concern as to “the ineffectiveness of the pathway for communicating information direct to the RDaSH Crisis Team”, | can state that there is a facility to: e signpost the patient to this service (or other crisis service dependent on geographical area); or e refer the patient to the their crisis team with consent and when already receiving care within the duration of the 999 call. The Trust currently does not offer a callback advice service once an ambulance response has been deemed not required by the police. This is necessary due to service delivery demands, resource limitations and a requirement to prioritise waiting 999 calls. In order to ensure that the position is clear to all involved in this complex area of health care, the Trust has: e reiterated to all its Mental Health Nurses that their role within the 999 call is that of a triage function. More specifically, it will be emphasised that if it has been determined that an ambulance response is not appropriate for the circumstances the call should be closed following signposting, onward referral or self-care advice if necessary and possible within the remit of the 999 call; e reiterated to all Mental Health Nurses within EOC that in circumstances where police have stated an ambulance response is not required but have identified that further and alternative mental health support is required, they should be clearly instructed (directly on scene or via their communications centre) that this facility of ‘call back’ and signposting is not provided by the Trust. The Trust also intends to improve communications by introducing a process whereby Clinical Hub staff within EOC, including the Mental Health Nurses, are able to make direct radio contact with police on scene at such incidents and advise them as appropriate. This can be used in situations where more information is required to determine appropriate action, or to simply inform of the role of the Trust once an ambulance response has been deemed inappropriate. The Trust has yet to roll out this process across its demographic however is currently discussing its implementation with the other police forces in the Trust's area of operation. The Trust is committed to improving mental health care for patients, recognises the complexities in this field and is cognisant that multi-agency working is critical to achieving best outcomes and appropriate care. To this end, the Trust is working within the Sheffield Crisis Care Concordat to ensure appropriate responses to the needs of people with mental health conditions, in association with SYP, Sheffield Health and Social Care Trust, Sheffield Teaching Hospitals, Sheffield City Council and NHS Sheffield CCG. This includes a review of the processes, roles and functions of ambulance and police described above. It is envisaged that once established, agreed best joint working solutions be rolled out to other areas. Review of the current process and communications between agencies is within the scope of the Sheffield Crisis Care Concordat. | apologise if the position above was not fully outlined in evidence at inquest. | am, of course, happy to discuss further with you any remaining concerns. Our thoughts remain with Mr Kiernan’s family. Yours sincerel Rod Barnes Chief Executive
See every Prevention of Future Deaths report matching Community health care and emergency services related deaths, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.