Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0386, written 28 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 | 28 Dec 2017 |
|---|---|
| Reference | 2017-0386 |
| Deceased | Michael Drewry |
| Coroner | Andrew McNamara |
| Coroner area | Nottinghamshire |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Nottinghamshire Healthcare NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
In re. the death of Michael Richard Drewry. REGULATION 28: REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Ruth Hawkins, Chief Executive, Nottinghamshire Healthcare NHS Foundation Trust; 1 CORONER I am Andrew McNamara, Assistant Coroner, for the coronial area of Nottinghamshire. 2 CORONER’S LEGAL POWERS I 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 3 May 2017 an Inquest was opened into the death of Michael Richard Drewry. That was concluded at the end of the inquest on 18 December 2017. The conclusion after the inquest was: Medical cause of death: Hanging How, when and where the deceased came by his death: Shortly after 09.00 on 3 April 2017 Mr. Drewry was discovered by his wife at the foot of the stairs at the family home in Beeston, Nottingham. Wrapped around his neck and the newel post at the foot of the stairs was blue fabric taken from some pyjamas that had been fashioned into a ligature. Despite CPR, resuscitation and emergency hospitalisation, Mr. Drewry suffered an unsurvivable hypoxic brain injury. In consultation with his family Mr. Drewry’s life sustaining therapy was withdrawn at 20.36 on 8 April 2017 and he died shortly after at 20.47 at the Queens Medical Centre Nottingham. Conclusion of the jury as to death: Mr. Drewry died as a result of injuries sustained from a self-administered ligature. 4 CIRCUMSTANCES OF THE DEATH The deceased had a background of periodic bouts of anxiety and low mood beginning in about 2007. His condition fluctuated and was, from time to time, well controlled with, amongst other drugs, fluoxetine. In January 2014 he required hospitalisation after an acute bout of anxiety in the workplace. Towards the conclusion of 2016 the deceased’s mental health began to deteriorate and, by February 2017, he required emergency hospitalisation. Matters were exacerbated by the death of his sister during his period as an inpatient. The deceased was discharged into the community. On or about 9 February the deceased held a knife and expressed a desire to ‘cut out the bad piece’ By late March the deceased’s mental health began to deteriorate. On 30 March he had a panic attack, held a knife to his chest and said ‘I would never do this but I can’t live like this’. Overnight in to 31 March he suffered a panic attack during which he injured his hand. His wife took him to A & E where he was prescribed diazepam. He was seen by a 1 consultant psychologist at home on 31 March. The deceased’s mood fluctuated and his wife rang the Crisis team in the early hours of 2 April 2017. He was seen at home at 10 am on 2 April 2017 by a nurse during which he explained how he had held a knife to his chest. During the consultation he calmed and denied strong urges to end his life. Medication was delivered later that day by a Community Support Worker who carried out no formal assessment of the deceased’s mental state. The deceased remained anxious and outwardly stressed about an impending visit from a psychiatrist and certain domestic building works that were being done at the time. In the morning of 3 April 2017 the deceased and his wife discussed the renovation work; he then became distressed as a result of his clothing splitting and remained anxious whilst his wife showered. His wife subsequently discovered the deceased slumped at the foot of the stairs with a ligature fashioned from pyjamas around his neck and the newel post. He sustained fatal injuries as a result and died on 8 April 2017. Following his death Nottinghamshire Healthcare NHS Foundation Trust prepared a Quality Improvement Plan dated 22 June 2017. Within it were 6 recommendations which raised issues with basic healthcare practice including such fundamentals as accurate note-taking and the appropriate route to escalate concerns about a patient. 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. 5 The MATTERS OF CONCERN are as follows. – (1) The failure of the Crisis Team to ensure consistency and continuity of care for the deceased, in particular the changing personnel who visited the deceased; (2) The failure of the Crisis Team to make accurate and prompt records of all consultations with the deceased; (3) The failure of the Crisis Team promptly to report/escalate any matters of concern to senior members of staff so that appropriate and timely steps could be taken in relation to the management of the deceased’s care including, if necessary, hospitalisation; 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you and/or your organisation have the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 22 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. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Parties/Persons: 1. 2. , Nottinghamshire Healthcare NHS Foundation Trust I 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 2 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 28 December 2017 Andrew McNamara 3
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.
INHS Nottinghamshire Healthcare NHS Foundation Trust The Resource [Trust HQ] Duncan Macmillan House Our Ref RH/cls Porchester Road 20 February 2018 Notgham Strictly Private & Confidential Tel: 0115 9691300 Andrew McNamara Assistant Coroner H.M. Coroners Office and Main Court The Council House Old Market Square j Nottingham j NG1 2DT Dear Mr McNamara Please find below the organisational response to the recently received Preventing Future Deaths Report following the unfortunate death of Michael Richard Drewry, the inquest of which was concluded on the 18 December 2017. We offer our sincere condolences to Michael’s family. 1. The failure of the Crisis Team to ensure consistency and continuity of care for the deceased, in particular the changing personnel who visited the deceased. Continuity of care is a challenge within our Crisis Resolution and Home Treatment Teams due to the service operating 24 hours a day, 7 days a week. Staff work 12 hour shifts and need to be able to respond swiftly to urgent referrals, within 4 hours and 24 hours whilst also maintaining robust care and treatment for those patients already on their caseload. It is acknowledged that continuity in a person’s care is important, however, the Crisis Teams fundamentally operate to respond to, manage and contain risk and therefore this is not always possible. For patients receiving the highest intensity of care (Red - RAG rating), which entails a person being seen one or more times per day, the consistency of staff is not possible and the challenge between intensity of clinical contacts and continuity in staff is acknowledged. For patients receiving care at a lesser intensity (Amber RAG and Green RAG rating) the Crisis Teams always attempt to provide continuity where possible within a team held caseload. The Trust is shortly to introduce the Modified Modified Continuity Index (MMCI) into its routine reporting systems, at both individual and team levels. This is a measure calculated using the total number of patient visits and the number of different clinical staff visiting the patients and gives a resulting score between 0 and 1, the more staff providing care to the patient the lower the score will be. The MMCl1 is due to be implemented in early April 2018 for a trial period in one team before full implementation to all Crisis teams. Once in place it will allow us to monitor which teams are managing consistency in care to enable learning to be spread across teams. ‘ | ( / po C | | 1S The Resource, Duncan Macmillan House, Porchester Road, Nottingham NG3 6AA a bout integrated healthcare. Chair: Dean Fathers, Chief Executive: Ruth Hawkins The MMCI will be integrated into an Individual Patient Reporting System and will be presented alongside other service delivery metrics and outcomes. These measures will facilitate individual health care professional (HCP) and team supervision. In addition, the Crisis Teams are currently also working with the commissioners in reviewing the service, taking in to account the current constraints of providing continuity of care across all Crisis Teams within Adult Mental Health, with the most recent meeting held in January 2018. At this meeting they were informed of the challenges surrounding continuity of care and have agreed to review the commissioning of the crisis services across Nottinghamshire. Whilst there is no timescale attached to this at present however, a task and finish meeting is being convened in March 2018. Finally, the Trust is working with Meridian Productivity Specialists over a period of 18 months, focussing on Mental Health Services to ensure the right resources in the right place at the right time with the right quantity and quality of care. The failure of the Crisis Team to make accurate and prompt records of all consultations with the deceased. Crisis Team staff are fully aware that contemporaneous notes must be recorded about the patient and must be written at the time of the event or as soon afterwards on the Trust Patient Information System (RiO). Staff have been instructed and trained to ensure that they comply with this process. To support them to do this they have been issued with the correct software and devices to enable them to achieve this whilst in the vicinity of the patient’s whereabouts. On occasion, staff do have to return to base due to the intermittent availability of the telecom service signal/network therefore delaying the entry on the RiO system. Staff have been reminded of the importance of this in team meetings (held 31/01/2018) and will be monitored ongoing in managerial supervision on a monthly basis. The failure of the Crisis Team promptly to report/escalate any matters of concern to senior members of staff so that appropriate and timely steps could be taken in relation to the management of the deceased’s care including, if necessary, hospitalisation; Crisis Team staff are fully aware the need to escalate any concerns regarding a difference in presentation of any patient. When staff are concerned following a contact with a patient, these concerns must be escalated to senior members of staff. This can be done through the daily handover of patients who are on RED in the RAG rating alongside any other patients causing concern and a doctor is present at these meetings. There is also a line management structure through which issues can be escalated to senior managers and staff have been reminded of this process which is included in the operational procedure. There are also two Multi-Disciplinary Team meetings (MDT) each week to ensure safe and effective management of the patients on amber and green. Any discussions held are recorded in RiO detailing the decisions and actions taken. Staff have been reminded of the importance of timely input in team meetings (held 31/01/2018) and reminded again in managerial supervision on a monthly basis. These actions will be monitored within the Trust through a specific Quality Improvement Plan with the General Manager as the nominated lead. These actions are regularly updated and require both Directorate and Divisional sign off. | hope the information above provides the assurance that we have considered your recommendations seriously and are actively seeking to improve the services we provide by implementing the actions outlined. Yours sincerely Ruth Hawkins Chief Executive Nottinghamshire Healthcare NHS Foundation Trust
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