Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0370, written 18 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 | 18 Dec 2017 |
|---|---|
| Reference | 2017-0370 |
| Deceased | Daniel Watson |
| Coroner | John Gittins |
| Coroner area | North Wales (East and Central) |
| Category | Mental Health related deaths · Community health care and emergency services 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.
John Adrian Gittins
Senior Coroner for North Wales (East and Central)
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
BCUBB, Ysbyty Gwynedd, Penrhosgarnedd, Bangor, Gwynedd LL57 2PW
Wrexham County Borough Council The Guildhall, Wrexham
CORONER
tam JOHN ADRIAN GITTINS, senior coroner, for the coroner area of North Wales (East
and 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 the 8th of June 2017 | commenced an investigation into the death of Daniel Watson
(DOB 24.6.87, DOD 5.6.2017). The investigation concluded at the end of the inquest on
the 8 of December 2017 and | recorded a narrative conclusion in the following terms
“On the 5! of June 2017 the Deceased was verified dead at his home address as a
result of placing a ligature around his neck, however the evidence does not establish his
intention to the necessary legal standard.” The cause of death was 1(a) Hanging
CIRCUMSTANCES OF THE DEATH
The Deceased was known to the Flintshire and Wrexham Community Mental Health
Teams and had been allocated a social worker on the Wrexham Team on the 7' of
December 2016 following a request from his Consultant Psychiatrist following a lengthy
delay in the transfer of his care from Flintshire. Focus for his support was on his
social/housing needs and there was no evidence of any up to date care and treatment
plan nor any evidence of comprehensive risk formulation. During the early part of 2017 a
number of social factors resulted in an apparent decline in Daniel Watson’s mental
health and on the 5!" of June 2017 he was found hanged at his home.
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 :-
4. The Concerns Root Cause Analysis Investigation undertaken by BCUHB revealed a
multitude of care and service delivery problems and contributory factors in relation to
the care and treatment of the Deceased which cumulatively represented missed
opportunities to improve his mental health and the evidence given at the inquest by
the social worker and community psychiatric nurse demonstrated a complete lack of
understanding and empathy in relation to these issues.
2. That there needs to be a significant improvement in the training of staff within the
CMHT in relation to their understanding of risk assessment and potential escalation
of concerns towards a formal psychiatric assessment.
Coroner's Office, County Hall, Wynnstay Road, Ruthin, LL15 1YN
Tel 01824 708047 | Fax 01824 708048
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and | believe your
organisations 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 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.
COPIES and PUBLICATION
| have sent a copy of my report to the Chief Coroner and to the following Interested
Person — The Family of the Deceased
lam 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.
Dated 18" December 2017
Signature
Senior Coroner for North Wales (East and Central)
Coroner's Office, County Hall, Wynnstay Road, Ruthin, LL15 1YN
Fel 01824 708047 { Fax 01824 708048
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.
6 Heddfan AMHU, oes G IG Bwrdd lechyd Prifysgol Ysbyty Maclor miscesam, Wrecsam, ofp, pic | BetsiCadwaladr 0 N HS University Health Board Heddfan AMHU, ‘ Wrexham Maelor Hospital, Wrexham, LL13 7TD Mr. John Gittins Ein cyf / Our ref: INC 125498 — INQ2821 County ha North Wales Eich cyf / Your ref: Wynnstay Road Ff6n / Telephone: 01745 586391 Denbighshire Gofynnwch am / Ask a LL16 1YN for: E-bost / Email: SE Dyddiad / Date: 2"4 February 2018 Dear Mr Gittins Re: Regulation 28 Response re Mr. Daniel Watson | write in response to the Regulation 28 issued on 18" December 2017 as a result of the Inquest into the death of Mr. Daniel Watson. In relation to your first matter of concern in that the Concerns Root Cause Analysis Investigation undertaken by BCUHB revealed a multitude of care and delivery problems which cumulatively represented missed opportunities to improve the Deceased’s mental health. As you are aware an action plan has been produced to improve on the service delivery and this has been provided to you. In relation to evidence given at the Inquest by the Community Psychiatric Nurse (CPN), | can confirm that the CPN was provided with an initial debriefing session to reflect on the delivery of evidence provided at the Inquest. Further debriefing and ongoing supervision will provide the opportunity for the CPN to optimise learning and provide a focus on their understanding and empathy for their continued professional development, which will be incorporated into their appraisal. An initial focused session for the wider team’s learning will be held around awareness of empathy towards families and transparency to the Coroner at Inquest In relation to your second area of concern relating to a significant improvement in the training of staff within the CMHT in relation to their understanding of risk assessment and potential escalation of concerns to a formal Psychiatric Assessment. The Wales Applied Risk Research Network (WARRN) Asking Difficult Questions and Formulating Risk (WARRN ADQ) is a National Programme of training, endorsed by Welsh Government, in the assessment, formulation and management of risk to self or others. One of the main aims of WARRN is to drive forward a standardised and consistent approach to risk assessment and formulation nationally, across services. The MHLD Division will continue to make available the WARRN Accredited Programme for Care Coordinators and new training dates have been confirmed for 2018 to be delivered through our group of specialised trainers. A copy of the training dates is attached. | can also confirm the CPN has previously received WARRN training in 2012. Cyfeiriad Gohebiaeth ar gyfer y Cadeirydd a'r Prif Weithredwr / Correspondence address for Chairman and Chief Executive: Swyddfa'r Gweithredwyr / Executives’ Office, Ysbyty Gwynedd, Penrhosgarnedd Bangor, Gwynedd LL57 2PW Gwefan: www.pbc.cymru.nhs.uk / Web: www.bcu.wales.nhs.uk Bwrdd lechyd Prifysgol Betsi Cadwaladr University Health Board | can also confirm that the MHLD Division will have updated the MHLD Supervision Guidance for Nurses and Support Workers Policy by the end of February 2018 to ensure staff can discuss and reflect on cases in a structured and facilitated process. A copy of the draft MHLD Supervision Guidance for Nurses and Support Workers Policy is attached. Assurance regarding compliance with appraisals and training is provided to the Senior Management Team on a monthly basis through the network teams performance report. Additionally, the MHLD Division has committed to undertaking a bi annual audit of Care and Treatment Plans using the Welsh Government recommended audit tool (see attached) which will be reviewed biannually within the divisions Quality and Safety Group and reported within our annual report on the local delivery of ‘Together for Mental Health’. Yours sincerely My, Andy Roach Cyfarwyddwr lechyd Meddwi ag Anabledd Dysgu Director of Mental Health and Learning Disabilities
Pennaeth Gofal Cymdeithasol i Oedolion / Cyfarwyddwr Gwasanaethau Cymdeithasol dros dro VI Head of Adult Social Care/Interim Director of Social Services Charlotte Walton Adeiladau’r Goron, 31 Stryt Caer, Wrecsam, LL13 8BG wrexham Crown Buildings, 31 Chester Street, Wrexham, LL13 8BG COUNTY BOROUGH COUNCIL Ff6n/Tel: 01978 292000 Ffacs/Fax: 01978 298029 BT Text Phone: 01978 292067 CYNGOR BWRDEISTREF SIROL www.wrexham.gov.uk www.wrecsam.gov.uk wrecsam John Gittins Eich Cyf/Your Ref HM Coroner’s Office Ein Cyf/Our Ref CW/ASC County Hall Dyddiad/Date 1 February 2018 Wynnstay Road Gofynner am/Ask for | Charlotte Walton Denbighshire E-pesie- tel LL15 1YN Dear Mr Gittins Re: Report for the prevention of future deaths — Inquest of Daniel Scott Watson Thank you for your letter of 15" December 2017 regarding the Regulation 28 Report. The response of Wrexham Adult Social Care is as follows:- Wrexham Adult Social Care accepts the recommendations highlighted in the Regulation 28 Report. The Department has discussed this matter with its partner agency, Betsi Cadwaladr University Health Board, with which it jointly provides the Community Mental Health Team Service. With respect to the evidence given at the inquest by the Social Worker involved showing a lack of understanding of issues and a lack of empathy, the member of staff concerned is to be given feedback and management supervision. The Mental Health and Learning Disability Supervision Guidance for Nurses and Support Workers Policy is being implemented by the BCU to improve discussion and reflection on cases in a structured and facilitated process and will apply also to social workers employed by Adult Social Care in the integrated team. A copy of this policy will be submitted by the BCU in its response. With respect to the issue of significant improvement in training of staff in Community Mental Health regarding risk assessment and escalation of concerns towards a formal psychiatric assessment, the Mental Health Learning Disability Division uses the Wales Applied Risk Research Network (WARRN) Asking Difficult Questions and Forumlating Risk training programme. This is intended to provide a consistent and standard approach to risk assessment. New training has been confirmed for 2018 and the staff that provided care to Mr Watson have been booked onto the training. In addition the MHLD Division will supplement the WARRN training with specific training on assessment of suicide. Adult Social Care Social Workers within the integrated CMHT service will be included within these training programmes. continued/... Rydym yn croesawu gohebiaeth yn Gymraeg. Byddwn yn ymateb i unrhyw ohebiaeth yn Gymraeg ac ni fydd hyn yn arwain at unrhyw oedi. We welcome correspondence in Welsh. We will respond to any correspondence in Welsh and this will not lead to any delay. /,..continued 2 I trust that you will find this response satsifactory. Please contact me if you have any fruther queries. Yours sincerely a Head of Adult Social Care/Interim Director of Social Services Rydym yn croesawu gohebiaeth yn Gymraeg. Byddwn yn ymateb i unrhyw ohebiaeth yn Gymraeg ac ni fydd hyn yn arwain at unrhyw oedi. We welcome correspondence in Welsh. We will respond to any correspondence in Welsh and this will not lead to any delay.
See every Prevention of Future Deaths report matching Mental Health related deaths, 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.