Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0458, written 28 Sep 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 Sep 2017 |
|---|---|
| Reference | 2017-0458 |
| Deceased | Conall Gould |
| Coroner | Emma Brown |
| Coroner area | Birmingham and Solihull |
| Category | Mental Health 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 THIS REPORT IS BEING SENT TO: Northern Health and Social Care Trust CORONER | am Emma Brown Area Coroner for Birmingham and Solihull CORONER’S LEGAL POWERS 1 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 23/05/2017 | commenced an investigation into the death of Conall Patrick Gould. The investigation concluded at the end of an inquest on 26th September 2017. The conclusion of the inquest was that Mr. Gould’s death was drug related. CIRCUMSTANCES OF THE DEATH Conall Patrick Gould died on the 13th February 2017 at the Queen Elizabeth Hospital in Birmingham having been admitted earlier that day after being witnessed to behave erratically and then collapse. Conall had a diagnosis of a delusional disorder, for which he had received inpatient treatment, anda history of drug. When last reviewed prior to discharge from inpatient psychiatric care at Holywell Hospital on the 30th January 2017 he had maintained a positive outlook and insisted that his most recent overdose was recreational and without any intention to cause himself harm. Following his discharge his behaviour did not give his family cause for concern that he would attempt suicide. Following a post mortem the medical cause of death was determined to be: 1 (a) ECSTACY USE 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. - 4. At the time of discharge from Holywell Hospital on the 30" January 2017 Mr. Gould had been referred to the community mental health team for a 7 day review and had been given an appointment on the 2" February 2017. There is no evidence in the Trust’s records that the time, date and location of this appointment was given to Conall or his parents. 2. The evidence of consuitant Psychiatrist, who saw Conall and his father on the 30" January 2017 was that he anticipated that the discharge nurse would tell Conall and his mother or father, as his carers, the date of his review at the point of discharge as this is the usual practice. 3. Mr. Gould, Conall’s father, gave evidence that not only were he and his wife not told verbally of the appointment nor were they given any written information about it: on a previous discharge from an inpatient stay at another — | had been given a letter setting out the appointment arrangements for his son following discharge. Conall was 21 at the time of his discharge on the 30" January and his parents had taken a very active role in his care. If they had been aware of the appointment they would have made every effort to secure Conall’s attendance, as it was, believing there to be no plan for follow up, they did not prevent him from Q i i travelling to Birmingham for a period of rest with relatives (during which time he took the fatal overdose of MDMA). 4. The evidence of i... conducted the RCA was that the Trust does not have a protocol or policy stipulating the arrangements for notifying services users and their carers of follow up arrangements on discharge and current practice does not require written confirmation of follow up arrangements to be given to the service user or their carers. 5. The system currently creates a risk that services users and their carers will not be aware of follow up appointments and therefore may not attend giving rise to a danger that opportunities to review the service user’s condition and treatment will be lost. 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 23" November 2017. 1, 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: 1am 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. 28/09/2017 Signature Emma Brown Kréa Coroner Birmingham and Solihull
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.
Northern Health #7 and Social Care Trust Ms Louise Hunt HM Senior Coroner, Birmingham & Solihull Areas The Coroner’s court 50 Newton Street Birmingham B4 6NE 26 March 2018 Dear Ms Hunt Mr Conall Patrick Gould Inquest held on 26 September 2017, Regulation 28 Report to Prevent Further Deaths Firstly, please accept my sincere apologies for the delay in this response to you. In relation to the matters of concern raised by you during the Inquest held into Conall’s death, | can now inform you of the actions the Trust has made to strengthen systems and processes of care to support patients and their families on discharge from hospital. The Trust has introduced into the Integrated Care Protocol (the in-patient clinical documentation record of the multi-disciplinary treatment team) a requirement for all patients, when being discharged from hospital, to receive written confirmation of their 7 day follow-up appointment with relevant telephone contact numbers if they require assistance in the immediate days following discharge. This protocol also directs that a relative/concerned other, identified by the patient, will also be provided with this written information when consent to do so has been given by the patient. Under the heading ‘Discharge Process’ on p5 , section 3 has been amended in reference to the information given to the patient on discharge and section 4 has been added in reference to the carer and the information that should be shared with them, with the agreement of the patient. In addition, on page 78, the Discharge Care Plan has been amended significantly to ensure both the patient and, if acceptable to the patient, the carer, are given a copy of the Discharge Care plan, Support plan and list of medication. The Trust believes this action adds a level of robustness to the existing discharge processes and addresses the concerns raised and | have attached templates of the documentation now provided to all patients. | would wish to thank you for raising this matter and would also advise it is planned that this protocol will be shared with Trusts across Northern Ireland at a workshop to be held on 6 June 2018. Trust Headquarters, Bretten Hall, Antrim Area Hospital, Bush Road, Antrim BT41 2RL Phone: 028 9442 4321 E mail: oscar.donnelly@northerntrust.hscni.net Yours sincerely Laer INS Oscar Donnelly Divisional Director of Mental Health, Learning Disability & Community Well-being MCM/GEN/LET/ CP GOULD TO AREA CORONER FOR BIRMINGHAM AND SOLIHULL 2 of 2
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