Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0369, written 13 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 | 13 Dec 2017 |
|---|---|
| Reference | 2017-0369 |
| Deceased | Rebecca Romero |
| Coroner | Maria Voisin |
| Coroner area | Avon |
| Category | Child Death (from 2015) · Hospital Death (Clinical Procedures and medical management) related deaths · Mental Health related deaths |
| Organisation named | Dorset Healthcare University NHS Foundation Trust · Avon and Wiltshire Mental Health Partnership NHS Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
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 (1)
NOTE: This form is to be used after an inquest.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
4. Avon & Wiltshire Mental Health Partnership NHS Trust
2. Dorset Healthcare University NHS Foundation Trust
3. NHS England. .
1 | CORONER . .
{am Maria Voisin, Senior Coroner, for the area of Avon. i
2 CORONER’S LEGAL POWERS |
| make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 , i
and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. i
3 | INVESTIGATION and INQUEST
On 28" July 2017 | commenced an investigation into the death of Rebecca Jay
ROMERO, aged 15 years. The investigation concluded at the end of the inquest on 13"
December 2017. : .
The medical cause of death was given as:
la Hanging
The conclusion was:
Accidental death contributed to by neglect
4. | CIRCUMSTANCES OF THE DEATH
Rebecca Romero died on 19" July 2017 at her home address. She had been found in
the bathroom with a ligature around her neck and she died from the injuries sustained.
Rebecca had been discharged from a psychiatric unit on 14" July 2017 and was under .
the care of the community team at the time of her death. She had not been seen since : : |
her discharge. : .
Rebecca had a long history of self harm and mental health problems; she was described
as appearing very vulnerable with very few factors of resilience. In June 2016 she began
using ligaturing as a means of self harm. It was agreed by a number of witnesses that
that elevated Becky's risk. .
On 10" June 2017 she was admitted to Pebble Lodge Adolescent Unit in Dorset as
there were no beds for her in the local area of Bristol at the Unit called Riverside.
On 6" July she was released fora period of leave; what in fact transpired was she never
returned to Pebble Lodge after this period of leave.
On 14" July there was a discharge meeting and a community care package was put into
place. . i
| was told that the original plan was to arrange to transfer Becky to Riverside but as
there was no place available attempts were made to discharge her to Riverside as a day. _ |
placement patient. Unfortunately there were no day placements available either and :
therefore a community care package was put into place. One witness described the
community care package as “it just didn’t feel very comfortabie.”
Furthermore the evidence at the inquest from NHS England was at the time of Becky's
discharge that a day patient placement was available at Riverside.
An independent witness also gave evidence at the inquest and said he was concerned
about the length of time that Becky was without a medical review and that post
discharge was at a very high risk time. He stated that the amount of contact from the 6"
July to the time of her death was not acceptable and that the plan to see Becky once a
week following her discharge was not sufficient.
A number of other points were raised at the inquest as follows:
¢ inrélation to the transfer from Pebble Lodge to Riverside it appears that a Form 1
was submitted to Riverside on 15" June but that the referral was closed on 6" July.
There appeared to be confusion by some as to whether this was being followed up.
e The community care plan that was in place from 14" July had no dates for tasks to
be completed or for meetings to take place, by way of example at the time of her.
death a medical review appointment was still not in the diary.
¢ Different people described Becky's risks in different ways, terminology such as low,
medium or high were used to describe her risk but others used significant or low and
even on the date of discharge her risks were described in different ways.
¢ Part of the care plan was for there to be communication by text with Becky up until
the time of her death there was only one text sent which was effectively confirming
an appointment for after her death and simply stating “how are you”. | was told that
there is no current training or guidance given to staff.
* This case highlighted some of the difficulties in transferring children to an in-patient
unit‘out of the area and then arranging to transfer them back to the area.
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) In this case there was confusion as to whether on an in-patient transfer there
should be a Form 2 to go alongside the Form 1 procedure. As well as clarifying
this process with all providers concerned consideration should be given thata
clear documented process is put in place for in-patient transfers so that all those
involved understand clearly the situation and the decision made in relation to the
- patient.
Consideration should be given to ensuring that all care plans are time specific
so that dates of meetings or dates for tasks to be completed are set at the time
of the meeting so again expectations are managed and everyone knows exactly
what the plan is and when actions will occur.
—
(3) That the issue of inconsistent terminology when assessing risk is reviewed to
ensure a consistent approach. In this case there were a number of different
phrases and grading’s used to determine the deceased's risk.
(4) That consideration should be given to training and/or guidance issued for staff
communicating with young persons by text or any means of social media.
Consideration should be given to reviewing whether there ought to be guidance
issued when managing children who go out of area for psychiatric in patient care
and further guidance issued in the management of children when returning to
their local area when they have been an in-patient out of area. Whether certain
steps should be taken to ensure best practice and a consistent approach e.g.
risk assessing; face to face meetings; robust care planning; parental
involvement; how best to re-integrate back into the local area/team.
6
ead
ACTION SHOULD BE TAKEN
in my opinion action should be taken fo 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,
namely by 2™ February 2018. 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.
COPIES and PUBLICATION
| have sent a copy of my report to the Chief Coroner and to the following other Interested
Persons — family, Off The Record. | have also sent it to the Local Safeguarding Board.
{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.
13" December 2017 MLE. Voisin oC.
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