Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0449, written 14 Jul 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 Jul 2017 |
|---|---|
| Reference | 2017-0449 |
| Deceased | Sabrina Walsh |
| Coroner | James Healy-Pratt |
| Coroner area | East Sussex |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Sussex Partnership NHS Foundation Trust |
| 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.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Secretary of State for Health 2. Sussex Partnership Foundation NHS Trust 1 CORONER lam James Healy-Pratt, assistant coroner, for the coroner area of East Sussex. 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 9 November 2016 | commenced an investigation into the death of Sabrina Michelle Waish, aged 32. The investigation concluded at the end of the inquest on 6 July 2017. The conclusion of the inquest was that Sabrina Walsh deliberately chose to attach a ligature to herself but the evidence does not fully explain whether or not she intended that the outcome be fatal. This was contributed to by neglect. 4 | CIRCUMSTANCES OF THE DEATH (JURY FINDINGS) The deceased was detained under the Mental Health Act as a patient in Woodlands Acute Care on 31 October 2016. She was found hanging with a ligature around her neck which had been slotted over the door through the closure. Sabrina deliberately tied and applied the ligature to herself. The lack of formal assessment had direct impact on Sabrina as if she had a risk assessment she would have been on correct observations therefore reducing the risk of self harm. The staff at Woodlands did not effectively appreciate the needs of Sabrina, which resulted in a serious failure of her care. If they had followed procedure and placed her on one to one observations this would have greatly reduced the opportunities to harm herself. Overail if correct procedures were followed they would have had a positive effect on Sabrina and the level of care received. By not following procedures this has had a clear and direct effect on her passing. This is a gross failing of medical care from staff at the Woodlands. 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. - The lack of CCTV in corridors and communal areas at Woodlands Acute Care, St Leonards on Sea, which would enhance location of vulnerable patients where observations do not immediately locate them. Valuable minutes would be saved in locating vulnerabie patients if CCTV was installed. 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 8 September 2017. |, 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: Birnberg Peirce, solicitors for the family. Care Quality Commission | 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 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. | i 1 \ } James Healy-Pratt 14 July 2017
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.
By MA; Mr James Healy-Pratt HM Assistant Coroner for East Sussex INHS| England Professor Sir Bruce Keogh . National Medical Director Skipton House 80 London Road Coroner’s Office (East Sussex) SE1 6LH 31 Station Road Bexhill on Sea East Sussex TN40 1RG 23 November 2017 Dear Mr Healy-Pratt Re: Inquest touching the death of the late Sabrina WALSH | am responding to your letter of 4 September 2017 with regard to the inquest into the death of Sabrina Michelle Walsh completed on 14 July 2017, noting that you have kindly granted a 60-day extension from 25 September 2017 to the required response date. Specifically, you had concerns that the lack of CCTV in corridors:and communal areas at Woodlands Acute Care, St Leonards on Sea was a factor in the unfortunate and regrettable death of Sabrina Walsh. | was saddened to read about her death. In preparing this response, | have taken advice from Professor Tim Kendall, the National Clinical Director for Mental Health for NHS England. | have also paid due regard to the relevant guidance as listed below: e Department of Health “Health Building Note 03-01: Adult acute mental health units” e CQC: “Using surveillance” 2014 e Information Commissioner's Office (ICO): “In the picture: A data protection code of practice for surveillance cameras and personal information” Version 1.2 e The Surveillance Camera Commissioner Code of Practice 2013 e The Social Care Institute for Excellence: “Electronic surveillance in health and social care settings: a brief review’ As previously discussed, the Department of Health guidance states that CCTV systems should not cover service user bedrooms or toilet and shower areas but that it could be used in service user corridors, day rooms, interview rooms, therapy rooms, vocational services, education spaces, visits rooms and reception lobbies. Should mental health providers choose to use CCTV, they should consult the CQC guidance “Using surveillance” 2014. This states that; “The decision whether High quality care for all, now and for future generations to use surveillance is for care providers to make in conjunction with the people who use the service... This document does not give guidance on whether or not you use surveillance and CQC does not require providers to do so.” \t also states that; “We would be concerned by an over-reliance on surveillance to deliver key elements of care, and it can never be a substitute for trained and well supported staff.” Consultation is recommended by the CQC at an early stage and also “from time to time throughout the use of surveillance”. The recommendations for use of CCTV in mental health units do depend on whether the unit is a Secure unit or not, and if it is a secure unit then CCTV would be more strongly recommended in medium or high security units as compared to low security units. Woodlands Acute Care, St Leonards on Sea is not a secure unit. It is Professor Kendall’s opinion that widespread use of CCTV in non-secure acute mental health units such as Woodlands would be intrusive and has the potential to cause anguish to patients who may be acutely distressed, paranoid or delusional. There is a balance which must be struck between risk avoidance and the creation of a therapeutic environment. In dealing with mental health patients, the healing environment and culture necessitates a small element of risk in order that service users feel empowered and confident to cope independently (and do not become institutionalised) when they are ready to return home. Enabling and encouraging patients to take some responsibility for their health in a supported way is an indispensable part of this healing process. In order to enhance patient safety with regard to acute non-secure mental health units, the preferred method is to support and encourage staff and patients to work collaboratively to enhance both patient safety and therapeutic risk taking and to anticipate and manage potential problems. Professor Kendall's advice for non-secure units such as Woodlands Acute Care is that CCTV would be advisable in the areas where people enter the unit such as the entrance and the main pathways in. However, it would not be advisable to have intrusive cameras in everyday areas such as common living areas shared by patients. CCTV should not be placed in bedrooms or shower areas. Any mental health unit should be able to explain to CQC how they use CCTV. and how this is justified taking into account the patient groups that they serve. In addition, they should take account of the guidance for use of CCTV in their unit which is helpfully set out in the documents listed above and which | will not rehearse here. ‘In secure units, particularly in medium and high secure units, a case can be made for CCTV use in all common areas. However, this is not so for non-secure units such as Woodiands Acute Care. In reaching his considered opinion, Professor Kendall has also taken into High quality care for all, now and for future generations account the patient’s right to respect for private and family life under Article 8 of the European Convention of Human Rights. Whilst Article 8 is a qualified right, it can only be interfered with when, amongst other things, to do so would be a proportionate response to any identified risk. Consequently, such an interference has to be justified and taken into account in the overall balancing exercise ’ referred to earlier in this letter (and in the guidance issued by the Department of Health, the CQC and the ICO). Professor Kendall is of the view that the current advice given to non-secure units regarding the use of CCTV is a proportionate response to any potential risks. The Sussex Partnership NHS Foundation Trust has consulted with patients and with staff on their wards on the subject of their perception of CCTV and of how this would affect their care and the perception of their environment. The responses were largely not in favour of installing CCTV..It was felt that use of CCTV in their unit “would be intrusive or increase their thoughts of paranoia.” Two respondents (out of the four wards asked) felt that “it would depend on how CCTV was used and that in some cases it could be a positive initiative for safety.” . The. Sussex Partnership NHS Foundation Trust has helpfully agreed with the guidance as set out by Professor Kendall above. They are currently reviewing their policies in relation to CCTV and they agree that installation of CCTV in © entrance areas would be beneficial. They have agreed to install CCTV in the entrance areas of the 12 sites where psychiatric intensive care units are situated. | hope that you have found this response helpful, and that we have balanced carefully the issues of patient safety with both patient experience and the therapeutic environment. Yours sincerely, be Pro éSsor Sir Bruce Keogh KBE, MD, DSc; FRCS, FRCP National Medical Director NHS England High quality care for all,.now and for future generations
A member of: INHS| Association of UK University Hospitals Sussex Partnership NHS Foundation Trust Our Ref: SA/jw Trust Headquarters Swandean 22 November 2017 Arundel Road Worthing West Sussex Mr James Healy-Pratt BN13 3EP Assistant Coroner for East Sussex ; 31 Station Road Bexhill on Sea East Sussex TN40 iRG Dear Mr Healy-Pratt Re: Inquest into the death of Ms Sabrina Walsh | write in further response to your Regulation 28: Report to Prevent Future Deaths of 14 July 2017. | am grateful to you for allowing us the opportunity to consult with interested parties and take a national steer in relation to installing CCTV to corridors and communal areas of Woodlands Acute Care Unit. Our consultation with patients/families and staff, has provided varying feedback. Of note was the range of differing opinion. The consistent feedback from the majority of patients was the concern that they would be watched; some expressing the belief that the presence of CCTV may increase feelings of paranoia. At the opposite end of the range, was a small -group of patients whose perception was that the installation of CCTV may make them feel safer. The carers/families rather mirrored this feedback, whereas the staff, on the whole, were not in favour. Notably, they highlighted the need to resource the viewing of the CCTV and were of the opinion that that resource could alternatively be used to enhance the engagement of patients. The national steer from NHS England (which I’m aware is being forwarded directly to you), now states that CCTV would be advisable in the areas where people enter the unit and the main pathways in. However, it would not be advisable to have intrusive cameras in everyday areas such as common living areas shared by patients. As a result of the information we now have available to us, | confirm that the Trust is in the process of implementing the installation of CCTV in the entrance areas of all our Acute Inpatient/PICU wards, which is a total of 12 sites, including Woodlands. Interim Chair: Richard Bayley Chief Executive: Samantha Alten Head office: Sussex Partnership NHS Foundation Trust, Swandean, Arundel Road, Worthing, West Sussex, BN13 3EP www. sussexpartnership.nhs.uk A teaching trust of Brighton and Sussex Medical School | trust that the contents of this letter and the action the Trust is taking is of assurance to you, but | would welcome any additional comments or feedback you may have that would further assist us in improving the services that we provide to our patients and their families. Yours sincerely y A Samantha Allen Chief Executive
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