Prevention of Future Deaths reports · 2017

Liam Thomas

Regulation 28 report to prevent future deaths, reference 2017-0347, written 4 Sep 2017. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report4 Sep 2017
Reference2017-0347
DeceasedLiam Thomas
CoronerDarren Salter
Coroner areaOxfordshire
CategoryHospital Death (Clinical Procedures and medical management) related deaths
Organisation namedOxford Health NHS Foundation Trust
Sourcejudiciary.uk record · original PDF
Responses published1

The report

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.

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS

THIS REPORT IS BEING SENT TO:

1. Mr Stuart Bell CBE, Chief Executive of Oxford Health NHS Foundation
Trust

CORONER

lam Mr D M Salter, HM Senior Coroner for Oxfordshire.

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

| concluded the inquest into the sad death of Liam Thomas at Oxford Coroner’s
Court on 28" July 2017. Mr Thomas died at Littlemore Hospital Oxford on 28"
August 2016. The jury returned a narrative conclusion as follows:

Liam was found in a shower room of the Phoenix Ward of Littlemore Hospital with
plastic bags over his head, secured in place with a shoelace, at about 14:00 on the
2g" August 2016, and pronounced dead at 15:21 at the John Radcliffe Hospital the
same day. The cause of death was asphyxiation.

At this time, Liam intended to take his own life. This intention was formed at a time
when his mind was disturbed and the following inadequacies in the provision of
mental health care at Littlemore Hospital contributed to his death: failure to ensure
patients safety in relation to a banned item (plastic bags) and failure to manage
items identified by staff to be of individual personal risk to Liam (ligature items).

There was written and oral evidence at the inquest which | vidence from
nursing staff and doctors from the Trust together wit Head of
Nursing for the Adult Directorate. The Trust were legally represented at the inquest.
A full copy of the inquest file was provided in advance. | have not therefore
provided you with a full copy of the inquest file with this letter.

CIRCUMSTANCES OF THE DEATH

The circumstances are briefly set out above in the narrative conclusion. As you will
know, Liam was 21 years old when he died on 28 August 2016. CPR was carried
out and he was taken to the John Radcliffe Hospital by ambulance but he was
pronounced death soon after arrival. He was a single man who lived with his
mother and sisier in Didcot. He worked in ICT as a Programming Developer. Liam
had suffered with mental health problems before his death including thoughts of
taking his own life. He was detained under Section 2 of The Mental Health Act 1983
on 11" August 2016 and remained an inpatient on the Phoenix Ward at Littlemore
hospital until his sad death.

CORONER’S CONCERNS

During the course of the Inquest the evidence revealed matters giving rise to
concerns. 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 make this
report to you.

The MATTERS OF CONCERN are in relation to plastic bags/restricted items and,
secondly, communications with family.

1 recognise that lessons have already been learnt following Liam’s death as set out
in the Route Cause Analysis investigation and, specifically, in the action plan. Ms
Klink gave further evidence about this.

In relation to the first concern, about plastic bags as restricted items on the ward,
the sad fact is that Liam was able to take his own life because he had access to
plastic bags. They were Sainsbury's bags. He attended Sainsbury's on Section 17
leave two days prior to his death. There was evidence that these bags were taken
from him on return to the ward. [t could not be ascertained if this was correct and
whether the bags which Liam used were bags which he obtained on the trip to
Sainsbury's or whether the bags were obtained in some other way on the ward. |
understand there have been improvements in the system in relation to plastic bags
in particular. | appreciate however that the problem of plastic bags is not straight
forward, particularly when one takes into account the fact that many patients are
informal patients and are free to leave and return and that visitors may also bring
plastic bags when visiting. | understand that there are clear warnings that plastic
bags are restricted items at the entrance io the ward and that steps are taken to
bring this to the attention of visitors. It would be helpful if | could be provided with
further details about the steps that are in place.

A related concern was the environmental searches that were intended, amongst
other things, to check for plastic bags. | was shown what are referred to as daily
environmenial safety check lists which include plastic bags/bin liners on them. | had
the impression from the evidence that, at the time, these checks were not being
carried out as regularly as they should be. Indeed, | see that recommendation 2 on
the RCA/Action Plan concerns standardising the frequency of environmental checks
and monitoring of banned items across all in patient wards. It states that they
should be carried out daily. It appears a policy is in place and a recommendation
but it is not clear to me whether there is effective implementation. Consequenily |
request that this matter be reviewed and that I receive a response specifically about
implementation.

The second area of concern is about communication with family. Again, | realise
that this is not a straightforward matter because there are issues of consent and it is
also the case that some families are not supportive or united. However, in Liam’s
case, it is clear that his family were very supportive and united in terms of Liam’s
health and wellbeing. A concern at inquest from the evidence was that there was a
need for improved communication in terms of information provided by family io staff
and also from the staff (particularly concerning elevated risk) to family members.
This will enable family to be more watchful. — in her evidence, referred to
the “triangular approach” and recognised that there was more work to be done in
this difficult area. She indicated that work was on going. It would be helpful if you
could provide details about the current policy and practice concerning
communications with family and if there is a programme in place, to improve it.

ACTION SHOULD BE TAKEN

In my opinion action should be taken to prevent future deaths and | believe you
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. | may extend the period on request.

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

! confirm that a copy of this report and your response will be sent to Liam’s family.

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.

=

Signed Date
it! Gdirbe Toit

4 Vv
Mr-B-M. Salter

| HM Senior Coroner for Oxfordshire

(on)

Responses

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.

Response from Oxford Health NHS Trust (PDF)
Mr D.M. Salter
HM Senior Coroner
Oxfordshire Coroner’s office

INHS

Oxford Health
NHS Foundation Trust

Chief Executive’s Office
Trust Headquarters
Warneford Hospital

Warneford Lane

The Oxford Register Office :
2"! Floor -
1 Tidmarsh Lane

Oxford OAS tk
OX1 INS . 2769

www.oxfordhealth.nhs.uk

20" October 2017
Dear Mr Salter,

Regulation 28 Report to Prevent Further Deaths following the inquest concerning the
death of Mr Liam Thomas

| am writing in response to your letter dated 4" September 2017, and the enclosed
Regulation 28 Report to Prevent Further Deaths following the inquest concerning the death
of Mr Liam Thomas.

The particular concerns raised by you were as follows:
1. Mr Thomas’ access to plastic bags which are a restricted item on the ward.
2. The consistency and standard to which daily environmental checks are carried out.

3. The communication with Mr Thomas’ family while he was an inpatient on Phoenix
ward.

| will address these in turn.
Concern 1

Plastic bags are a restricted item on all wards. There are posters displaying this in the ward
reception areas, and on several points inside the wards. Staff are requested to draw all
visitors and patients attention to this and to remove any restricted items before anyone
enters the ward environment. Plastic bags are a very common item, and are regularly
brought to the ward. Mr Thomas’ sad death drew our attention to the fact that there had been
an inconsistent approach to managing this across our wards. Some staff were removing the
bags at reception, but at other times visitors (especially regular visitors) were asked to take
the items to the patient's room and then return the bag to the nursing office, but there was no
way of checking if this had been done. Following this incident clear guidance was issued to

all staff that plastic bags must be removed at reception, if this is impractical, staff must
accompany the visitor or patient to the patient’s room, allow them to remove the items and
remove the bag, disposing of it or placing it in patient's locker which can only be accessed
under staff supervision.

We have added a column to the visitors’ signing in book for staff to confirm that all visitors
and returning patients have been advised about restricted items and asked to hand over any
such items they may be bringing on to the ward. Staff will be required to complete this, which
will be monitored by matrons weekly by checking the visitor’s book, at the same time as the
monitoring of environmental checks.

In addition, we looked at alternative safe ways for patients and visitors to bring items on to
the wards, and ordered paper bags to be available on all wards as an alternative to carrying
items in plastic bags. Staff will offer this as an alternative to visitors at the reception area,
and for patients who bring back items when they enter the ward

The advice on restricted items on wards has also been added to the Admission Information
packs, and included on the admission check list for staff to complete. Admission checklists
are audited by the ward matrons on a monthly basis.

Our carer and family information pack given to families on admission also contains
information about restricted items. The distribution of the family information pack is included
in the admission check list, which is monitored monthly by the ward matron

Concern 2

Following this sad incident we also became aware that the recording of the daily
environmental checks was inconsistent. All staff interviewed were clear that this had to be
done a minimum of once daily, and there was evidence that this was consistently allocated
at the start of each shift. However the recording of it was inconsistent and we therefore did
not have sufficient evidence that it had actually been carried out.

A new standard operating procedure (SOP) for carrying out environmental checks was
devised and an example of the form is included at appendix 1.

Matrons are now required to review the checks carried out on a weekly basis to ensure
consistency in reporting, and ensure that any gaps in recording are addressed directly with
staff. Matrons are reporting on their monitoring monthly to the senior matron.

In addition we are currently trialing several different versions of the form to ensure that it
supports staff fully in carrying out this important task. We expect to make a final
decision on a form to be used by all by end of October 2017.

Concern 3

The Trust is signed up to the ‘Triangle of Care’ 6 principles of involving carers, family and
friends. We were very disappointed to learn that Mr Thomas’ family did not feel adequately
communicated with during his inpatient admission. This was complicated by the fact that Mr
Thomas was unsure about the extent to which he wanted staff to communicate and at times
asked staff not to inform his family of how he had presented on the ward. However, we
recognise the crucial role families play in a patient's recovery and the importance of ensuring
that families feel involved and supported through what is often a very difficult time.

The team on Phoenix ward have been facilitated to reflect on this incident, particularly the
experience of Mr Thomas’s family, and since this incident a lot of work has taken place to
improve the support and involvement of carers across adult services.

We have devised a Carer’s Handbook (attached at appendix 2) and all wards have ‘welcome
leaflets’ explaining the practical workings of the ward such as visiting times and restricted
items. The Carer’s Handbook has been devised for use by our community teams as well as
inpatient wards, in recognition of that fact that family (or carer) involvement in care is equally
important in both settings. There is an expectation that all workers distribute these
appropriately as well as them being widely available in outpatient clinics and ward reception
areas. The handbooks are also made available at various Family and Carer events, forums
and reference groups which are regularly held locally by teams. Staff are regularly reminded
to distribute the handbook to patients’ friends and family through their monthly business
meetings.

We have also employed a full time Patient and Carer Experience lead, who is overseeing the
Carer and Family surveys which we co-designed with carers, and which provide direct
feedback to wards and community teams about the experience of carers and families, and
gives teams the opportunity to liaise directly with carers about the improvements they are
making.

Earlier this year we introduced a new tool called IWantGreatCare which asks patients and
carers a series of questions about their experience of the care they have received and give
them opportunity to leave free text feedback. This is immediately received by team
managers so they can respond dynamically to concerns raised. The tool is available online
and on paper, and we rely on staff on wards and in community teams to ask patients and
carers to give feedback, as well as posters and materials in wards and outpatients clinics
advertising the feedback tool. In addition our patient and carer engagement lead regularly
visits all services to work with managers to ensure plans are in place to address the
feedback teams receive and hold open surgeries in wards and outpatient clinics encouraging
patients and carers to give feedback. Staff also have an app on their ipads which they can
encourage patients and carers to use to give feedback after their contact with them. We
monitor the responses by team monthly which is reported in our leadership meetings, and a
report on patient experience is forwarded to the board of the Trust on a quarterly basis. This
allows us to identify teams where feedback is low, and address this on a local basis.

\WantGreatCare also allows people to leave specific comments about individual staff
3

members and request contact from the team manager.
Additional concerns

| note that, in your covering letter to the Regulation 28 report, you also raised queries
regarding the processes surrounding the removal and return of risk items from patients, for
example at times of heightened risk. Specifically you enquired whether it is recorded when
items are removed from or returned to patients. Patients may access their secure lockers on
a frequent basis throughout the day, and are always observed by staff when doing so,
recording all items going in and out of lockers would be extremely labour intensive, however
when banned items are found and removed from patients this is recorded in their clinical
notes. In addition all patients have individual care plans which detail the care delivered
including the management of risk, and therefore any items which are not considered safe for
that individual based on their specific risk assessment will be recorded in that plan.

| also note your separate letter, dated 4 September 2017, following your inquest into the sad
death of Mr Andrew Crawford, in which you again identified concerns regarding
communication with family. | hope that the matters you raised are addressed in this letter,
specifically in the section relating to ‘Concern 3’ above. | acknowledge your intention to share
a copy of this letter with Mr Crawford's family.

In addition to the above, the Trust carried out a Serious Incident (SI) Investigation which you
have already received. An independent outside investigator was appointed to carry this out
and the report highlighted a number of recommendations which have all now been
completed.

The above actions as well as those highlighted in the SI report were taken in order to reduce
the risk of this very sad incident happening again. We will continue to monitor our adherence
to our policies and standards. | hope the information in this letter provides you with
reassurance that appropriate action has been taken to improve the safety of our
environments and address the issues you helpfully highlighted in your Regulation 28 Report.
If you require any clarification of further information, do not hesitate to get in touch.

Yours sincerely

Se Sox

Stuart Bell, CBE
Chief Executive Officer

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