Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0362, written 8 Dec 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 Dec 2017 |
|---|---|
| Reference | 2017-0362 |
| Deceased | Benjamin Goodrum |
| Coroner | Jacqueline Lake |
| Coroner area | Norfolk |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Norfolk and Suffolk NHS Foundation Trust |
| 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.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Chief Executive Norfolk & Suffolk NHS Foundation Trust Hellesdon Hospital Drayton High Road Norwich NR6 5BE 1 | CORONER | am JACQUELINE LAKE, Senior Coroner, for the coroner area of NORFOLK 2 | 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. 3 | INVESTIGATION and INQUEST On 15 November 2016, | commenced an investigation into the death of BENJAMIN THOMAS GOODRUM, AGED 35. The investigation concluded at the end of the inquest on 5 DECEMBER 2017. The conclusion of the inquest was medical cause of death: Unascertained and Conclusion: Open 4 | CIRCUMSTANCES OF THE DEATH Mr Goodrum was diagnosed with Schizophrenia and Asperger's syndrome. He lived in the community and received support from his parents, Norfolk County Council, MIND, and NSFT. He was under the Long Treatment Team (NSFT) and was due to receive a depot injection once per month. There were difficulties engaging with Mr Goodrum by the organisations and by his family. Mr Goodrum was last seen by support workers on 24 May 2017 and by his father 4 weeks prior to his death. His last telephone call was recorded as being on the 16 June 2017. Mr Goodrum was found in his flat clearly deceased on 27 June 2016. 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) Although there was evidence of good communication between the various organisations involved with Mr Goodrum and attempts were ongoing to retain contact with him, there was no one person taking overall responsibility for Mr Goodrum. (2) Mr Goodrum had originally been allocated a Care Co-Ordinator but on this person leaving, no new Care Co-Ordinator was appointed. (3) The Serious Incident Investigation recommended all service users receiving active treatment should be allocated a Lead Care Professional or a Care Co-Ordinator and this action was to be completed by 30/04/2017. At the time of the inquest this action had not been put in place and the Action Plan was regarded as complete. (4) Evidence was heard that alternative measures have been taken within the various teams to ameliorate the lack of sufficient Care Co-Ordinators for service users, for instance using a team-based approach, but that such measures are not as effective as service users having a specific individual appointed as a Care Co-Ordinator. 6 7 | YOUR RESPONSE ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe your organisation has the power to take such action. You are under a duty to respond to this report within 56 days of the date of this report, namely by 5 February 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. 8 | COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the following Interested Persons: MIND Norfolk County Council | have also sent it to the: Care Quality Commission & Healthwatch Norfolk who may find it useful or of interest. | 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. 9 8 December 2017 a Tie acneseeteteeeesessneneuceseesanene Jacqueline Lake Senior Coroner Norfolk Coroner Service 69-75 Thorpe Road Norwich NR11UA
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.
NHS Norfolk and Suffolk NHS Foundation Trust Trust Management 1° Floor Admin Our Ref:ML/JC Hellesdon Hospital Private and Confidential Drayton High Road Ms Jacqueline Lake Hellesdon HM Coroner Norwich NR6 5BE Norfolk Coroner's Service 69-75 Thorpe Road Norwich Norfolk 22 January 2018 Dear Mrs Lake Regulation 28 report following the inquest of Mr Benjamin Goodrum | write in response to your report dated 8 December 2017. Under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 you requested the Trust consider issues of service delivery following the conclusion of the inquest into the death of Mr Goodrum. The matter of concern you raised was in respect of the long term treatment team that provided care to Mr Goodrum. You referenced the Trust's Root Cause Analysis (RCA) investigation recommendation that all service users receiving active treatment should be allocated a Lead Care Professional or a Care Coordinator but received evidence at the inquest detailing this was not yet in place. You heard evidence of the actions the Trust takes to mitigate this risk but that such measures were not as effective as having an individually allocated worker. The RCA report and your finding confirm the challenge of providing safe and effective services when clinical teams experience vacancies. The Trust recognises the impact this has for service users, families, carers and staff. The clinical team involved in the case (Central Norfolk Long Term Treatment Team) currently has one band 5 vacancy which is being recruited to. Organisationally, whilst we are doing comparatively well compared to other Mental Health Trusts, with a clinical vacancy rate of 10.5% compared to the national average of 13.7%, recruitment is one of the most significant challenges the National Health Service faces, both nationally and locally. Recruitment is a key aspect of the Trust's Workforce and Organisational Development Strategy in order to support ensuring staff with the right skills are deployed in the right place at the right time. Actions to support recruitment include: * Reducing the time it takes to hire staff. A lean process review has been undertaken resulting in the timeframe being reduced from sixteen to ten weeks; this is in line with the regional average. * We have implemented a new recruitment system, TRAC, which provides a greater level of information to candidates, recruiting managers and recruitment officers on progress and action required. This includes a dashboard to assist in the prioritisation of activities. * We have engaged a partner organisation to support us in promoting career opportunities within the Trust through social media. The use of social media now forms a key aspect of our recruitment approach. e ‘ Chair: Gary Page Chief Executive: Julie Cave ay #2, Working together Trust Headquarters: Hellesdon Hospital, Drayton High Road, Norwich NR6 SBE “= for better mental health Tel: 01603 421421 Fax: 01603 421341 www.nsft.nhs.uk «We have action plans in place for ‘hotspot’ areas that are particularly challenging to recruit to. These include short term tactical as well as medium to longer term plans. * In light of the national skills shortages, a key aspect of our recruitment approach is on growing our own staff. This includes accelerated pathways from apprenticeships to foundation degrees through to nurse training in order to become registered practitioners. + We are continuously reviewing our skill mixes. + We are working closely with our bank provider to increase our bank capacity to ensure a ready supply of appropriately skilled temporary staff to provide short term cover where needed. Alongside this, whilst our retention rate is generally good, we are also undertaking work to support the retention of experienced and engaged staff. This is includes encouraging retirees to return to work following retirement on a flexible basis, a significant focus on supporting staff wellbeing and a continued focus on embedding our Trust values and putting listening into action. Thank you for bringing the matters to the Trust's attention. If | can be of any further assistance please do not hesitate to contact me. Yours sincerely Cpa Julie Cave Chief Executive
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