Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0394, written 14 Nov 2017. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 14 Nov 2017 |
|---|---|
| Reference | 2017-0394 |
| Deceased | Brian Stannard |
| 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: 1. NORFOLK & SUFFOLK NHS FOUNDATION TRUST 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 BRIAN STANNARD, AGED 64 YEARS. The investigation concluded at the end of the inquest on 26 OCTOBER 2017. The conclusion of the inquest was Medical Cause of Death: 1a) Drowning and Conclusion: Mr Stannard was found drowned on the beach at Gt Yarmouth but the evidence does not fully explain whether he intended that the outcome be fatal. 4 | CIRCUMSTANCES OF THE DEATH Mr Stannard was a resident at Eversley Nursing Home at Gt Yarmouth. At approximately 5.30 am on 14 November 2016 Mr Stannard was seen by Carers in his room asleep. Noises were heard on the floor of Mr Stannard’s bedroom. The evidence does not reveal | whether the noises heard were investigated. At about 6.50 am that morning a body was found on the beach at Gt Yarmouth which was identified as that of Mr Stannard. Mr Stannard was declared dead at the scene. The evidence does not reveal how Mr Stannard left the Home and got to the beach area. 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) Mr Stannard had mental ill health and physical ill health. He was placed at a Nursing Home to manage his physical ill health as this was seen as the priority at the time of admission. Staff at the Home were not adequately equipped to deal with his mental ill health as his physical health improved. This not only raises concern with regard to the safety and well-being of the individual concerned, but also with regard to the staff involved in Mr Stannard’s care. They were not trained mental health individuals and were required to deal with attempts at and threats of self-harm and suicide by Mr Stannard. There did not appear to be a Home available where staff were adequately trained to deal with a person’s mental and physical ill-health. Records of staff were not always completed or fully completed. Staff are now provided with laptops to aid flexibility with regard to record keeping. It is understood staff are now required to complete their records by the end of each shift. Due to the volume of work, it is not clear if members of staff are given sufficient time and space to see the service user and then to write up their records during the same shift. (2 ~ (3) Due to volume of work, some staff may be completing their records in their own time. (4) The Lorenzo computer system was brought in some years ago. It does not appear to be fully operational and used to its full potential by all staff. 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. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 15 January 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 (son) Eversley Care Home Care Quality Commission Healthwatch Norfolk tam 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. 14 November 2017 [SIGNED BY CORONER] (ace
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 Our Ref:ML/JG 1% Floor Admin Hellesdon Hospital Private and Confidential Drayton High Road Ms Jacqueline Lake Hellesdon HM Coroner Norwich Norfolk Coroner's Service NR6 5BE 69-75 Thorpe Road Norwich Norfolk 22 January 2018 Dear Mrs Lake Regulation 28 report following the inquest of Mr Brian Stannard | write in response to your report dated 14 November 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 Stannard. Mental and Physical ill health Your report identified Mr Stannard had mental and physical ill health. He was placed at the nursing home to respond to his physical health needs as they were the presenting priority at the time of admission. As this improved you note that staff at the home were not adequately equipped to respond to his mental health needs. You further observe there did not appear to be a home available where staff were adequately trained to deal with a person’s mental and physical ill health. You raise an important issue regarding the provision of a range of accommodation services that can support individuals with complex and fluctuating needs. Such provision of accommodation is outside of the direct control of the Trust. The Trust’s role is to continually monitor the service user's presentation and to help facilitate changes where these are required. For Mr Stannard, this would have involved working with him, his family, the care home, continuing healthcare services and the GP. The Trust's Root Cause Analysis (RCA) investigation identified there was evidence of inter-agency working noting a routine review meeting was held on 7 November 2016. This meeting observed Mr Stannard’s continued physical and mental health presentation, identifying plans to assist with his benefit entitlement and to seek advocacy support to assist with decisions about potential future physical events. It was agreed the placement continued to meet his needs. Tragically, Mr Stannard died a few days iater. Completion of records Your report confirmed the findings of the RCA report that aspects of Mr Stannard’s health record had not been maintained to the expected standard, notably risk assessment and care plans. The Trust are engaged in a programme to improve its performance in this area with active monitoring at all levels of the organisation. The Trust recognises there are many influencing factors affecting this and are working with Clinical teams to ensure they have the right number of staff and equipment to ensure work can be allocated in a consistent and balanced way. 2 @, Chair: Gary Page Chief Executive: Julie Cave se Working together Trust Headquarters: Hellesdon Hospital, Drayton High Road, Norwich NR6 5BE = for better mental health Tel: 01603 421421 Fax: 01603 421341 www.nsft.nhs.uk Electronic Patient Record system Your report noted the Lorenzo electronic patient record system was introduced some years ago but that it does not appear to be fully operational and used to its full potential by all staff. The report does not detail the specific areas of concern. The Lorenzo computer system was implemented across the Trust in May 2015, replacing paper records and, in some areas, consolidating separate electronic systems into one. This has improved clinical safety by providing access to clinical information regardless of location and improving communications between different teams caring for the same patient. The system is fully operational, however the Trust is aware and is addressing some issues with it. Staff are currently receiving site visits from business change and training specialists to continue to develop their use of the system and the Trust is working with the system suppliers to improve its performance and usability. 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 COoiCacis Julie Cave Chief Executive
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