Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0361, written 16 Nov 2017. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 16 Nov 2017 |
|---|---|
| Reference | 2017-0361 |
| Deceased | Stephanie Cave |
| Coroner | Philip Spinney |
| Coroner area | South Wales Central |
| Category | Mental Health related deaths · Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
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
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT DATED 5 DECEMBER 2017 IS BEING SENT TO:
Group Chairman, Ludlow Street Healthcare.
Family of the deceased Stephanie Cave.
Deputy Chief Medical Officer, Welsh Government.
Chief Coroner.
CORONER
{am Philip Charles SPINNEY, Area Coroner, for the coroner area of South Wales
Central.
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
} On 18 August 2016 an investigation was commenced into the death of Stephanie Cave.
The investigation concluded at the end of the inquest held on 6 November to 16
| November 2017. The conclusion of the inquest was the answers to a series of
questions raised by me and answered by the Jury:
In summary the Jury concluded that Miss Cave intended to take her own life. They j
further concluded that there were no acts or omissions in the overall care and treatment
given to Miss Cave that probably contributed to her death.
CIRCUMSTANCES OF THE DEATH
Stephanie Cave first started to experience a deterioration in her mental health in 2013
when she first started restricting her diet; later there was a significant deterioration in her
functioning with self-harming, obsessional compulsive behaviour and speaking of
hearing a derogatory voice associated with self-harming behaviour. She made a number
of attempts to end her life. She had two periods of admission to hospital the second in
September 2015 when she was admitted to the Dorothy Pattison Hospital under the
provisions of the Mental Health Act. In January 2016 she was transferred to
Heatherwood Court, a private hospital operated by Ludlow Street Healthcare as her
needs could not be met on an acute ward. Miss Cave initially appeared to show
improvement in her clinical state with her mood and affect improved. However, there
were regular incidents of self-harm and of tying ligatures around her neck. In the
months of May and June there were multiple incidents which required intervention by
staff. Following this there was a sustained improvement commencing from the 7 July.
However on the 17 August 2017 she was discovered with a ligature around her neck
which sadly led to her death.
-
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.
CORONER'S CONCERNS
The MATTERS OF CONCERN are as follows:
(1) The evidence revealed that there was an inconsistent approach taken by staff
when conducting and recording enhanced observations on patients detained
under the Mental Health Act and at risk of self-harm and suicide when asleep.
(2) The evidence also revealed that there was no training provided and no written
guidelines on how such observations should be completed and how they should
be recorded in the observation forms.
(3) The evidence also revealed that precise times of such observations were not
routinely being recorded.
ACTION SHOULD BE TAKEN
(1) Consideration should be given to reviewing the process of conducting and
recording enhanced observations of patients detained under the Mental
Health Act and at risk of self-harm or suicide.
(2) Consideration should be given to introducing training and written
guidance on how to conduct and record enhanced observations of
patients detained under the Mental Health Act and at risk of self-harm or
suicide. |
;
In my opinion action should be taken to prevent future deaths and | believe you and your
organisation 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,
namely by 30 January 2018. |, 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
| 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.
Mr Philip C Spinney
HM Area Coroner
2 responses 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.
Professor Chris Jones Dirprwy Brif Swyddog Meddygol Deputy Chief Medical Officer Mr P C Spinney Area Coroner for South Wales Central The Coroner’s Court Central Police Station Cathay’s park Cardiff CF10 3NN January 2018 Dear Mr Spinney Regulation 28 Report to Prevent Future Deaths – Stephanie Monica Cave Thank you for your letter enclosing your Regulation 28 report following your investigation into the death of Stephanie Monica Cave. You will wish to be aware that Healthcare Inspectorate Wales (HIW) completed an unannounced focussed inspection of Heatherwood Court on 24 and 25 September 2017. The purpose of the visit was to assess whether Heatherwood Court Hospital is appropriately managing risk, specifically in relation to self harm and suicide. This inspection was in response to HIW being notified of the death of a detained patient (Stephanie Monica Cave). As with your investigation, HIW raised a number of concerns in regards to the observation of patients detained under the mental health act. In response to HIW’s concerns Heatherwood Court provided an implementation plan of actions they have taken/would take. These actions included – A review of training materials and an update to enhanced observation practice. An amendment to observation recording sheets to explain to staff what action is required in relation to the patients required level of observation. In addition the NHS Wales Quality Assurance Improvement Team (QAIT) undertook an immediate assessment of the clinical observation procedure within the hospital through an unannounced inspection on 9 January 2018. QAIT were informed of concerns raised through your Regulation 28 report and deployed clinical members to assess the site. Concerns were again raised in relation to observations which included gaps in observation and enhanced observation records and the sign off of day shift forms which highlight any action required/completed addressed. QAIT will continue to work with the provider to ensure these concerns are addressed and appropriate action is taken. Parc Cathays, Caerdydd CF10 3NQ Cathays Park, Cardiff CF10 3NQ Ffon/Tel: 029 2082 3911 Ebost/Email:PSChiefMedicalOfficer@wales.gsi.gov.uk The statutory Code of Practice (for Wales) 2016 to the Mental Health Act 1983 sets out specific guidance in relation to the practice of clinical observation given in chapter 26 and applies to Independent as well as NHS mental health hospitals/units in Wales. The overarching clinical imperative is that there should be a clear local policy on the clinical observation of patients as an integral aspect of patient engagement and the assessment and management of safety concerns. The Code addresses specific points of relevance to the matters of concern you raise regarding the process of conducting and recording the clinical observation of patients and staff training. In addition, the Code references relevant guidance issued by the National Institute of Clinical Excellence’s (NICE). We have sent copies of the Code of Practice on the Mental Health Act to the Operational Manager of Heatherwood Court and all units in Wales under the management of Ludlow Street Healthcare. I hope you find this response helpful. Yours sincerely PROFESSOR CHRIS JONES
Ludlow Street Healthcare & Heatherwood Court Hospital Response to Regulation 28: Report To Prevent Future Deaths Issued by Mr Philip C Spinney, HM Area Coroner, 6 December 2017 Action required by Coroner Consideration should be given to reviewing the process of conducting and recording enhanced observations of patients detained under the mental Health Act and at risk of self-harm or suicide Action Rationale To consider current policy in relation to the matters of concern raised by the Coroner e.g. by clearly outlining training provided to staff Review and update Levels of Observation Policy for ratification by the Policy Committee Circulate and implement new policy Review current enhanced observation recording documentation Introduce amended recording documentation for 2 week trial commencing 22 January, 2018 with provision for coaching of staff, monitoring and evaluation Introduce evaluated amended documentation Person responsible for action Date for completion , Registered 31 January 2018 Manager, with Operational and Board involvement Policy Committee 12 February 2018 , Registered 26 January 2018 Manager, with Operational involvement , Registered 4 February 2018 Manager, , Clinical Lead Manager with Unit Manager support with administrative support 5 February 2018 Consideration should be given to introducing training and written guidance on how to conduct and record enhanced observations of patients detained under the mental health Act and at risk of self-harm or suicide Amend documentation form used for recording enhanced observations to include additional guidance on conducting and recording enhanced observations & additional requirement to record actual time that observation is undertaken Update current training package to include: video that clearly shows the correct way to complete the documentation exemplar copies of completed for the finalised documentation record To promote more consistent approach by staff in their conducting and recording of enhanced observations and to increase the amount of information recorded To provide more specific training and guidelines for staff in respect of completing and recording their observations , Registered 19 January 2018 Manager , Clinical 12 February 2018 Lead Manager
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