Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0429, written 30 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 | 30 Nov 2017 |
|---|---|
| Reference | 2017-0429 |
| Deceased | Lindsey Hassall |
| Coroner | Alison Mutch |
| Coroner area | Manchester South |
| Category | Community health care and emergency services related deaths · 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: the Chief Executive of Pennine Care, the Chief Executive of CGL (Change, Grow, Live), the Practice Manager of Heaton Norris Health Centre. CORONER tam 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 15" November 2016 | commenced an investigation into the death of Lindsey Theresa Hassall .The investigation concluded on the 8" November2017 and the conclusion was one of Narrative: Died as a result of suspension from a ligature whilst under the influence of a cocktail of alcohol and drugs. The medical cause of death was 1a hanging Lindsey Theresa Hassall had a subarachnoid haemorrhage in 2012. She had a history of substance abuse, primarily alcohol. She sought help from drug and alcohol support services and from mental health services and her GP in the 12 months preceding her death. On 16th October 2016, Lindsey Hassall was taken to the 136 Suite by Greater Manchester Police officers and seen on 17th October 2016. She had been seen whilst on a bridge. Her behaviour following her arrest and at the 136 Suite was volatile and she attempted to harm herself. This behaviour is not within the 136 documentation. She was not detained under the Mental Health Act and was discharged back to her GP. There was no referral to Healthy Minds or the Crisis Team. She saw a Lifeline worker subsequently on 31st October and 3rd November. No suicidal ideation was seen. It was not known she had been seen at the 136 Suite. On 1st November 2016 she went to Stepping Hill Hospital due to concerns about ‘Spice’ ingestion. She was discharged without a referral to RAID. No suicidal ideation was expressed. It was not known that she had been seen in the 136 Suite on 16th 6 referral was discussed or made. October 2016. Her GP saw her on 7th November. It was known that she had been to the 136 Suite in 2016 and that there had been previous suicidal thoughts. A referral was not made to the Crisis Team/Community Mental Health Team. An assumption was made that this had been done by the 136 Suite. it was clear from the 136 documentation that this was not the case. On 10th November 2016 Lindsey Hassall spoke to her Lifeline worker via telephone. An appointment was made for 23rd November 2016. She gave a positive impression. It appeared that she had been living rough in Heaton Norris Park for some of the time since 1st November 2016. On 11th November 2016 her body was found at Heaton Norris Park, seated under a tree, attached by a ligature that was around her neck. Toxicology taken after her death revealed that she had consumed alcohol 118mg% (blood), amphetamine, propranolol, promazine and sertraline prior to her death. Sertraline and promazine were at significant and potentially fatal levels. 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. — e There is no provision for a record to be kept of the information, which Police Officers provide verbally to the RAID practitioners in the s.136 suite. The inquest heard that there was a record of the initial circumstances but no further record was kept. (Pennine Care) » Lifeline now known as CGL had dealt with the deceased in the period leading up to her death. The notes relating to that engagement were not input into the electronic system at the time. The inquest was told that the electronic system was updated from the notes after her death. Contemporaneous notes were then destroyed by the worker on the advice of her manager. (Lifeline/CGL) e The documentation held by Pennine Care was not easily accessible to all of the staff working for Pennine Care which meant that the full history of engagement was not known to workers dealing with her. ® The form completed by the 136 suite team was sent to the GP with the box refer to GP ticked. After receipt by the GP practice there was an assumption that any necessary referral had already been made and no 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. 1—__.. tN 7 | YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 25" January 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 | have sent a copy of my report to the Chief Coroner and to the following Interested Persons namely ii father of the deceased 2) Greater Manchester Police 3) Stepping Hill Hospital, 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 1 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 HM Senior Coroner 30/11/2017
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.
Pennine Care NHS Foundation Trust Corporate Services Trust Headquarters 225 Old Street Ashton-under-Lyne Lancashire OL67SR Telephone: 0161 716 3000 25" January 2018 PRIVATE & CONFIDENTIAL Ms A Mutch Assistant Coroner Coroner's Court 1 Mount Tabor Street Stockport SK1 3AG Dear Ms Mutch Re: Lindsey Theresa Hassall Thank you for your Regulation 28 report dated the 30" November 2017, and for bringing to my attention the concerns you had after hearing all the evidence. Your concerns relevant to Pennine Care have been reviewed, and the Trust's response is outlined below. Concern 1: There is no provision for a record to be kept of the information, which Police Officers provide verbally to the RAID practitioner in the s.136 suite. The inquest heard that there was a record of the initial circumstances, but no further record was kept. Response: A plan has been prepared to ensure that staff record information from a verbal handover from the police on a paper history sheet and ensure the assessing doctor and AMHP have access to this so they can review the information. This will be uploaded onto PARIS once the assessment is completed. The following actions are in place: » Advice to be included in staff briefing. = Flowchart to be developed which reflects guidance in staff briefing — laminated copy to be displayed in 136 suite so it is available ‘to staff coordinating and undertaking s136 assessments. » Include in the local induction processes. » Add flowchart to the s136 Standard Operating Procedure and policy. Sefe/ As Visit us at www-penninecare.nhs.uk aK ‘< Concern 2: Lifeline, now known as CGL, had dealt with the deceased in the period leading up to her death. The notes relating to that engagement were not input onto the electronic system at the time. The inquest was told that the electronic system was updated from the notes after her death. Contemporaneous notes were then destroyed by the worker on the advice of her manager. Response: Not a PCFT issue — no further action. Concern 3: The documentation held by Pennine Care was not easily accessible to all of the staff working for Pennine Care which meant that the full history of engagement was not known fo workers dealing with Ms Hassall. Response: As part of the above plan the following actions are in place: = Remind staff that they need to be aware of the process to access notes in and out of hours. If they are new staff members of not familiar with PCFT systems they should seek the assistance of a colleague. = Where a patient is brought to the 136 suite for assessment the staff coordinating the s136 will support this process if required. « Advice to be included in staff briefing. = Advice to be included in flowchart to be developed which reflects guidance in Staff briefing — laminated copy to be displayed in 136 suite so it is available to staff coordinating and undertaking s136 assessments. « Include in the local induction processes. Concern 4: The form completed by the 8136 suite team was sent to the GP with the box ‘refer to GP’ ticked. After receipt by the GP practice there was an assumption that any necessary referral had already been made and no referral was discussed or made. Response: « Remind all junior doctors that if a person is to be referred back to the care of their GP they make this clear in the summary letter sent to the GP. « Advise staff that where a service user requires a PCFT pathway following s136 assessment that the assessment team are to make the referral and document the action in the care record and in the summary letter sent to the GP. * Advice to be included in staff briefing. = Advice to be included in flowchart to be developed, which reflects guidance in staff briefing — laminated copy to be displayed in $136 suite so it is available to staff coordinating and undertaking $136 assessments. = Include in the local induction processes. eae Visit us at www penninecare.nhs.uk. | hope this response assures you that the Trust takes seriously any concerns that you raised, Yours sincerely x hecho C ff Claire Molloy Chief Executive Aa &* 3 = 9 Sra? Co < Va < Visit us at www.penninecare.nhs.uk. Dr Marshall & Partners Heaton Norris Health Centre Telephone (0161) 480 3338 Cheviot Close Fax (0161) 429-9369 Heaton Norris Practice Code: P88011 Stockport SK4 1JX www.drmarshallandpariners.co.uk Coroner's Court RECEIVED 1 Mount Tabor Street 18 DEC 2017 Stockport “ SKI3AG Juana -—¥ 14th December 2017 Dear HM Coroner, Re: Regulation 28 Report following inquest of Lindsey Hassall Thank you for bringing the above report to our attention. The full details of your report and this case have been reviewed and discussed at a practice meeting involving all relevant practice staff. We have looked in particular at the fourth bullet point in section 5 of your report headed “Coroner’s concerns”. The relevant practice policies have been reviewed and, as a result of this case and the Regulation 28 Report, a new policy has been implemented to ensure that when notification of an assessment by the RAID team on a section 136 is received by the practice, patients will be contacted and invited for review with a GP to ensure appropriate follow up is in place. The practice took the opportunity to review the clinical care provided to this patient. It was noted that on review of the clinical records, it was clear that a full clinical assessment was made when the deceased attended for review at the surgery. The assessment shows that the deceased was planning for the future, seeking a sick note for future benefits and engaging with the appropriate services. Appropriate follow up with the GP was discussed and arranged. No additional onward referral was necessary at that time. I trust this is satisfactory. Yours sincerely, Dr C Marshall On behalf of The Partners.
See every Prevention of Future Deaths report matching Community health care and emergency services 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.