Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0459, written 14 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 | 14 Dec 2017 |
|---|---|
| Reference | 2017-0459 |
| Deceased | Ernest Smith |
| Coroner | Anna Crawford |
| Coroner area | Surrey |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Surrey and Borders Partnership 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 THE SURREY CORONER’S COURT
IN THE MATTER OF:
__________________________________________________________
The Inquest Touching the Death of Ernest Wayne Smith
A Regulation 28 Report – Action to Prevent Future Deaths
__________________________________________________________
1 THIS REPORT IS BEING SENT TO:
Fiona Edwards
Chief Executive
Surrey and Borders Partnership NHS Foundation Trust
18 Mole Business Park
Leatherhead
Surrey
KT22 7AD
2 CORONER
Ms Anna Crawford, HM Assistant Coroner for Surrey
3 CORONER’S LEGAL POWERS
I make this report under paragraph 7(1) of Schedule 5 to The Coroners
and Justice Act 2009.
4
INVESTIGATION and INQUEST
An inquest into the death of Ernest Smith was opened on 22 June 2016. It
was resumed and concluded on 13 December 2017.
The medical cause of death was found to be:
1a. Hanging
The inquest concluded with a short form conclusion of ‘Suicide’.
5 CIRCUMSTANCES OF THE DEATH
On 13 June 2016 Mr Smith was found deceased in an area of woodland at
Chelsham Common in Warlingham.
In 2011 Mr Smith had been diagnosed with depression and begun on
1
anti-depressants by his GP,
Warlingham.
of Elizabeth House Medical Practice,
In April 2015 Mr Smith was referred to the Tandridge Community
Mental Health Recovery Service (CMHRS) at Langley House in Oxted,
which is part of Surrey and Borders Partnership NHS Foundation Trust
(SABP).
In June 2015 Mr Smith was referred to
Psychologist at the CMHRS who saw him from August 2015 to May 2016.
Mr Smith was also referred to the Enabling Independence Service and
was provided with a Care Co-ordinator, but he did not engage with
either.
, a Senior Clinical
Mr Smith’s GP remained responsible for prescribing his anti-depressant
medication and continued to see Mr Smith regularly.
evidence that she was concerned that he was not improving despite an
increase to his anti-depressant medication.
gave
On 31 July 2015 she contacted the CMHRS and requested that he be seen
by a psychiatrist to review his medication. A medical review was
was
arranged on 20 August 2015 but Mr Smith did not attend.
not informed that Mr Smith had been offered an appointment, or that he
had not attended, and Mr Smith was not offered a further appointment,
in contravention of the standard procedures in place at the time.
From March 2016 onward
significant decline in Mr Smith’s presentation.
gave evidence that she had noticed a
On 7 March 2016 she wrote to the CMHRS describing the deterioration
and requesting a medication review. The court heard evidence that Dr
Parry’s letter was considered at an Allocation Meeting on 15 March 2016,
but did not result in a medical review.
, the team’s Consultant
Psychiatrist, accepted that Mr Smith ought to have been offered a medical
review at that time but it was not possible to establish why it had not
happened.
telephoned
On 16 May 2016
make an appointment for Mr Smith.
appointment was not made prior to his death. It was not possible to
establish exactly why the appointment was not made but it was most
likely as the result of administrative error.
directly and asked him to
agreed to do so but the
2
gave evidence that she was not informed about numerous
instances when Mr Smith either did not attend or cancelled appointments
with
ordinator.
, the Enabling Independence Service or his Care Co-
6 CORONER’S CONCERNS
Following Mr Smith’s death a Root Cause Analysis investigation was
conducted by the Trust and the court was told that a number of changes
have been introduced and that further training has been provided.
However, there remain two broad areas of concern.
The MATTERS OF CONCERN are:
- The system for considering correspondence received from GPs,
including requests for medication reviews, appears to remain
the same as the system which was in place at the time of Mr
Smith’s death and which failed to identify
for a medical review on 7 March 2016.
request
- There are a number of CMHRS service users who, like Mr
Smith, are not under the CMHRS medical team, but whose care
is led by other members of the multi-disciplinary team,
including clinical psychologists and care co-ordinators. The
court heard that there is a clear system in place in the medical
team for updating GPs on progress and also in the event of
failures to attend appointments (DNAs). However, it did not
appear to the court that there was a clear system for updating
GPs when the medical team was not involved in a patient’s
was in this
care. This risks GPs being unaware, as
inquest, of instances in which their patient begins to display
signs of disengagement with the service.
Consideration should be given to whether any steps can be taken to
address the above concerns.
7 ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I
believe that the people listed in paragraph one above have the power to
take such action.
8 YOUR RESPONSE
You are under a duty to respond to this report within 56 days of its date; I
may extend that period on request.
3
Your response must contain details of action taken or proposed to be
taken, setting out the timetable for such action. Otherwise you must
explain why no action is proposed.
8 COPIES
I have sent a copy of this report to the following:
1.
2.
3. Care Quality Commission
4. The Chief Coroner
, Elizabeth House Medical Practice
In addition to this report, I am 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.
Signed:
ANNA CRAWFORD
DATED this 14 day of December 2017
4
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.
28" February 2018 Private and Confidential Ms Anna Crawford HM Coroner’s Court INHS Surrey and Borders Partnership NHS Foundation Trust Chief Executive Office Trust Headquarters 18 Mole Business Park Leatherhead Surrey KT22 7AD Tel: 01372 216008 Fax: 01372 217100 Station Approach Woking Surrey GU22 7AP Dear Ms Crawford Ernest Wayne Smith (deceased) Regulation 28 Report to Prevent Future Deaths (PFD) I am writing further to the PFD report that you sent to Surrey and Borders Partnership NHS Foundation Trust (the Trust) in relation to Mr Ernest Smith, who sadly died on 13th June 2016. Thank you for taking the time to investigate his death so thoroughly and for bringing the matters of concern you have about the Trust’s practices to our attention. The PFD report has been carefully considered and discussed by the Trust’s Adult Mental Health Division, within which the Community Mental Health Recovery Services are located. The Division has created the attached action plan, which outlines the actions that the Division is going to take in order to address your concerns. | hope the action plan is self explanatory. The action plan is going to be monitored and followed up at the monthly Adult Mental Health Directorate Quality Assurance Group meeting, which is attended by the Director and the Associate Medical Director for the Division. In addition to this, the action plan will be shared with the other three service Divisions, to ensure that the learning can be applied and rolled out across the Trust as a whole. Your PFD report was presented at the private Trust Board meeting in January 2018 and the action plan will also be submitted to the Board in due course. On behalf of the Trust, | would like to offer our sincere condolences to Mr Smith’s relatives for their loss and hope that our action plan assures you and them that we have learnt and continue to learn from his death. Please do not hesitate to contact me or Dr Justin Wilson, Chief Medical Officer, should you require any further information. Yours sincerely, LA her Jonathan Warren Acting Chief Executive
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