Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0305, written 23 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 | 23 Oct 2017 |
|---|---|
| Reference | 2017-0305 |
| Deceased | Sian Witheridge |
| Coroner | Mary Hassell |
| Coroner area | Inner North London |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths · Other related deaths |
| Organisation named | Camden and Islington 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
Siân Louise WITHERIDGE (died 30.05.17)
THIS REPORT IS BEING SENT TO:
1. Ms Wendy Wallace
Chief Executive
Camden & Islington NHS Foundation Trust (C&I)
4th Floor, East Wing
St Pancras Hospital
4 St Pancras Way
London NW1 0PE
2. Mr John Gregory
Chief Executive
One Housing Group
Crisis House
18 Highbury Grove
London N5 2EA
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 5 June 2017, I commenced an investigation into the death of Siân
Louise Witheridge, aged 36 years. The investigation concluded at the
end of the inquest on 10 October 2017. I made a determination at
inquest of death by suicide.
1
4
CIRCUMSTANCES OF THE DEATH
Ms Witheridge hanged herself at home on 30 May 2017.
She had been detained in hospital under a section of the Mental Health
Act on several occasions. She then contacted the crisis team on 20 May,
attended an emergency unit on 22 May and, at her crisis team
assessment on 24 May, reported staring at traffic for hours considering
jumping into it. She also told her care co-ordinator that she had a rope
to use to hang herself.
She was admitted to Highbury Grove Crisis House (operated by
OneHousing) on 25 May.
She wanted to self discharge on Saturday the 27th but, having spoken to
a member of the crisis team at some length, agreed to stay. The plan
was for the crisis team to visit each day, for her to have a session with
Highbury Grove staff twice a day, and for her risk to self to be reviewed
prior to any leave being granted. She saw an advanced practitioner at
crisis house on Monday, 29 May.
She was planned for crisis team review next on 31 May, but on 30 May
she left Crisis House in the morning and was found by police at her home
that evening.
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. While Ms Witheridge was staying in Crisis House, her mental
health records were not available to the OneHousing staff there.
2. I was told that the written risk assessment provided to Highbury
Grove Crisis House was not as detailed as it should have been.
I was unable to make a judgement about this myself because no
member of the treating teams or those advising them brought the
records to court.
(This is especially disappointing given that it is a specific
instruction contained within every witness summons that was
signed and returned.)
2
3. The crisis team staff (as opposed to the crisis house staff) did
have access to Ms Witheridge’s mental health records, but they
did not read them any further back than the date of her first call to
crisis house during that last episode, i.e. 25 May 2017, despite
her very extensive past medical history.
There seemed a lack of recognition of the importance of the notes,
particularly the older notes. This may explain why no member of
the team thought to bring the notes to court for the inquest.
4. One of the crisis team nurses made a plan for a risk assessment
to be carried out before Ms Witheridge took any leave.
However, this was an unenforceable plan, because Highbury
Grove is an open facility.
If the crisis team nurse had considered this, he might have
decided that Ms Witheridge in fact needed an assessment under
the Mental Health Act when she sought to self discharge on 27
May.
5. There seemed a lack of understanding by the staff of the
difference between a patient answering positively that they have
no suicide plan and a patient simply refusing to answer a question
about a suicide plan.
False reassurance appeared to have been drawn from the latter.
No arrangement was made for the crisis team to meet Ms
Witheridge on 30 May.
6. The care offered to service users of Highbury Grove Crisis House
and the Islington Crisis Team seemed disjointed and not
dovetailed between OneHousing and Camden & Islington NHS
Trust.
For example, the crisis team members who gave evidence did not
have any knowledge of the crisis house procedure for risk
assessing before allowing leave.
I found it difficult to make further assessment of this because of
the lack of medical records, and the presentation to me of the
serious incident investigation report only the day before inquest.
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.
3
7
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date
of this report, namely by 18 December 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.
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
, adult social care, Camden, Islington & Enfield
, brother of Siân Witheridge
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
23.10.17
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.
Coroner ME Hassell Senior Coroner Inner North London St Pancras Coroner’s Court Camley Street LONDON N1C 4PP Dear Madam INHS| | ; Camden and Islington NHS Foundation Trust Executive office 4" Floor, East Wing St Pancras Hospital 4 St Pancras Way London NW1 OPE Tel: 020 3317 7016 www.candi.nhs.uk 11" December 2017 Prevention of future deaths report — Sian Witheridge | write further to your Regulation 28 Prevention of Future Deaths report dated 23 October 2017 in which you highlighted concerns about the care provided to Ms Witheridge. You have brought to our attention a number of concerns which | will address below. 1. While Ms Witheridge was staying in Highbury Grove Crisis House her mental health records were not available to the OneHousing staff there. We agree that Highbury Grove Crisis House staff should have access to our clinical records. To this end, we have been working with One Housing to enable members of their staff to acquire access to our IT system. We are aiming to have shared access in place in early 2018 following staff completing the relevant training and necessary checks. 2. You were told that the written risk assessment provided to Highbury Grove Crisis House was not as detailed as it should have been. We have reviewed our risk assessment and | have enclosed a copy for your information. We are satisfied that it contains a comprehensive risk history and that it includes sufficient detail about previous suicide attempts and risk factors. This risk assessment would have been provided to Highbury Grove as Highbury Grove does not accept referrals without first reading the risk assessment. As above, going forward, Highbury Grove staff will be able to access our risk assessments and obtain all the relevant information about a patient's previous risk history and current risk factors. Chair: Leisha Fullick Chief Executive: Angela McNat EScamden # ISLINGTON Cal is an NHS Camden an Your partner in CRI care & improvement NHS} We are also going to move to undertaking joint risk assessments which will be completed by One Housing and C&l staff members. This will ensure that all risk factors as identified by all the staff caring for the patient are taken into account when formulating risk assessments and next steps. In cases where C&l staff conduct the risk assessment themselves, the Operations Manager and Team Manager for the crisis teams have reinforced to the teams the importance of providing detailed feedback to One Housing staff and agreeing a written plan of action for each patient. We are sorry that we did not bring the medical records to the inquest. We will ensure that we do so in the future. . The Crisis Team Assistant Practitioner who saw Ms Witheridge on 29 May 2017 did not read any further back than the date of her first call to the crisis house i.e. 25 May 2017 despite her very extensive past medical history. The Assistant Practitioner acknowledged at the inquest that she should have read further back in the clinical records than she did. To ensure that the learning from this case is embedded within the teams, the operational manager and team manager of the crisis team have reinforced the importance of undertaking a comprehensive review of the clinical records, including reading the risk assessment, before seeing a patient. The practice of reading the history will be checked in regular supervisions . One of the Crisis Team nurses made a plan for a risk assessment to be carried out before Ms Witheridge took any leave. However, this was unenforceable because Highbury Grove is an open facility. If the crisis team nurse had considered this he might have decided that Ms Witheridge in fact needed an assessment under the Mental Health Act when she sought to self-discharge on 27 May. The nurse in question was unable to attend the inquest to explain his plan. However, he was certainly aware that Highbury Grove is an open facility and that Ms Witheridge could not have forcibly been prevented from leaving the premises. The nurse's intention in asking Highbury Grove staff to check in with Ms Witheridge before she took any leave was for them to obtain an impression of her mental state and to make an assessment as to whether she was safe to leave. If staff considered that Ms Witheridge was at immediate risk of self-harm before leaving the premises then immediate action could have been taken such as trying to persuade Ms Witheridge to stay or calling emergency services. As such, whilst the nurse was aware that Ms Witheridge could not be detained at Highbury Grove, he was ensuring that an additional check was undertaken before she left the premises. This is not dissimilar to the assessment which would take place with an informal patient before they leave a ward. We do not consider that the nurse’s action in this instance was inappropriate. A mental health assessment was an option that the crisis team was actively considering. However, they did not consider it was needed when Ms Witheridge sought to self-discharge on 27 May. The Assistant Practitioner agreed with Ms Witheridge that she would write down her thoughts on Paper and pass this on to Highbury Grove staff as she was struggling to engage verbally with them. When the Assistant Practitioner her team, she verbally fed back her concerns about Ms Witheridge’s mental state to senior staff On shift. The plan which was agreed was for a 6. The care offered to service users of Highbury Grove Crisis House and the Islington Crisis Team seemed disjointed and not dover tailed between OneHousing and Camden & Islington NHS Trust. We are aware that Highbury Grove has sent you our ‘Working Protocol’ setting out how our teams work together. As set out earlier, we accept that there have been challenges with information sharing. We are confident however that this has been rectified and Highbury Grove and staff will in the future have ready access to all the relevant clinical information. We would like to assure you that we have good channels of communication with Highbury Grove, and our senior operational staff meet with the Highbury Grove team regularly to discuss how the service is working, and to identify whether there are problems in particular areas. Following this inquest we have also agreed to jointly investigate all deaths connected to the Highbury Grove Crisis House to ensure that a holistic approach is taken so that all service delivery problems are identified. | hope that the information in this letter assures that you we have taken forward the learning from this case, and our ongoing commitment and determination to keep all our patients safe. Yours sincerely u\ Angela McNab Chief Executive Enc: 1
See every Prevention of Future Deaths report matching Camden and Islington NHS Foundation Trust, 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.