Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0385, written 22 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 | 22 Dec 2017 |
|---|---|
| Reference | 2017-0385 |
| Deceased | Russell Robb |
| Coroner | Alison Mutch |
| Coroner area | Manchester South |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| 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 of Trafford Clinical Commissioning Group, Trafford Adult Safeguarding Board. CORONER lam Alison Mutch, senior coroner, for the coroner area of South Manchester 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" April 2016 | commenced an investigation into the death of Russell Charles ROBB. The investigation concluded on the 24" November 2017 and the conclusion of the jury was narrative: Mr Robb did not intend the outcome to be fatal. Mr Robb had taken a fatal combination of prescribed and non-prescribed drugs, mixed with alcohol. Due to Mr Robb's vulnerable mental state along with his level of intoxication, it is more likely than not that Mr Robb was unaware of the high level of substances that he consumed. Mr Robb displayed very anxious, aggressive and erratic behaviour, which were heightened after receiving a letter regarding his benefits. In the past, it is evident that there was a lack of communication between multiple agencies along with the fact that Mr Robb failed to comply and engage with professional help. There was inadequate monitoring of Mr Robb's administration of prescribed drugs. The medical cause of death was 1a Combined Drug Toxicity; and 2 ischaemic Heart Disease Mr Robb died on 9th April 2016 at 20:27pm at Manchester Royal Infirmary. Mr Robb had taken a cocktail of drugs (prescribed and non-prescribed) along with a substantial amount of alcohol prior to his death. During the early evening of Sth April 2016, Police officers forced entry to Mr Robb's property, discovering him in a collapsed state. CPR was administered by both Police Constables, the ambulance and fire service attended. The fire service attempted to resuscitate using a defibrillator. Mr Robb was transferred to A&E at Manchester Royal Infirmary, where further means of resuscitation took place. At 20:27pm, Mr Robb was pronounced dead. 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. which ultimately led to his death. There was no evidence of regular reviews of his medication. There appeared to be no guidelines in place to reduce the quantity of drugs available to Mr Robb at any one time. (CCG; Secretary of State for Health) 2. There was limited evidence of information sharing between the members of the Trafford Adult Safeguarding Board. This meant that the Local Authority were unaware of the volume of interaction between the Police and Mr Robb.(Adult Safeguarding Board).As a result only 1 strategic meeting took place over a 6 year period 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, namely by 16" 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 Persons namely a, partner of the deceased 2) Greater Manchester Police 3) J the Delamere Practice, who may find it useful or of interest. 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. Alison Mutch OBE HM Senior Coroner 22/12/2017
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.
e TRAFFORD & NHS} Independent Chair w Trafford Strategic Safeguarding Board Trafford Adult Safeguarding Board Trafford Town Hall, Talbot Road if you don't do something, who will? Stretford, Manchester, M32 OTH Eri www.trafford.gov.uk Date 1 March 2018 Dear Ms Mutch, Re: RCR | am writing to you further to your correspondence of 21st December 2017.Firstly , | would like to apologise for the delay in replying. At paragraph 5.2 you raised as a Matter of Concern the limited evidence of information sharing between the partners of Trafford Safeguarding Adults Board and in response | would like to share the following information. In terms of what action has been taken to improve practice in Trafford, Greater Manchester Police (GMP) now record high volume callers more accurately, identifying those that come into contact with the police more readily, thereby enabling earlier identification of individuals with complex needs and communication of these concerns with the Local Authority. The GMP function that prioritises and allocates cases in Trafford now sits within the Partnership Office at Stretford Police Station — co-located with the Anti-Social Behaviour Team and neighbourhood police teams - to enable more effective problem solving and decision making at lower levels of concern. From mid-February 2018, more complex individuals will be discussed at daily vulnerable adult meetings between the relevant Detective Sergeant at GMP and Local Authority social care managers. There are also advanced plans in place which will lead to a number of GMP staff being co- located at Trafford Town Hall to work alongside health and social care colleagues to support better communication and a joined-up approach in responding to concerns about vulnerable individuals who come into contact with services. In the meantime, GMP’s Public Protection Investigation Unit has relocated from Altrincham to Stretford Police Station, next door to Trafford Town Hall, making face-to-face meetings and communication easier to facilitate. The adult social care Screening Team relocated to Trafford Town Hall in December 2016 to sit alongside its children’s social care equivalent and our health safeguarding colleagues. This has helped us to share information more quickly and provide more effective, all-age responses to safeguarding concerns. We have updated the Terms of Reference of our TARGet (Trafford Adults at Risk Group} meeting to facilitate better information sharing between safeguarding partners and improve multi-agency risk assessment and risk management planning with regard to supporting adults at ongoing risk of harm. We now have a more robust and effective process in place. The revised policy is attached. Section 42 within the Care Act 2014 formally recognises self-neglect as a category of abuse and neglect. Trafford has responded to the most recent change in legislation by developing specific, relevant multi agency training and the first session is due to commence on 26th March 2018. Trafford had launched more generic multi-agency safeguarding training in early 2017. At a strategic level, we are in the process of redesigning our Safeguarding Boards and developing a more effective, integrated children and adults structure, whilst ensuring that a unique focus on each group is retained. We now have an all age integrated health and social care structure to deliver community services in Trafford, facilitated by a Section 75 agreement between Trafford Council and Pennine Care NHS Foundation Trust. This has enhanced our ability to look at whole family approaches to address needs and concerns and made information sharing between health and social care staff more straightforward. We will monitor and regularly review all new arrangements and processes to ensure that they have led to the desired improvement in practice. | hope that this information offers sufficient reassurance that the appropriate action is being taken in response to the issues raised. Please do not hesitate to contact me if you require any further information. Yours sincerely, MLA Nee Fe Independent Chair Trafford Safeguarding Board
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