Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0031, written 29 Jan 2018. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 29 Jan 2018 |
|---|---|
| Reference | 2018-0031 |
| Deceased | Michael Vukovic |
| Coroner | Philip Barlow |
| Coroner area | London Inner (South) |
| Category | 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.
ANNEX A
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1)
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
41. Chief Executive, Oxleas NHS Foundation Trust
1 | CORONER
{ am Philip Barlow, assistant coroner, for the coroner area of Inner South London
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 24 July 2017 | commenced an investigation into the death of Michael Vukovic, age
22. The investigation concluded at the end of the Inquest on 22 January 2018. The
conclusion of the inquest was:
Medicai cause of death:
1a Hypoxic brain injury due to prolonged cardiac arrest
1b Prolonged cardiac arrest
1¢ Traumatic L1 vertebral fracture and lumbosacral soft tissue haemorrhage
The narrative conclusion was as follows:
Mr Vucovic jumped from a building while suffering psychosis.
4 | CIRCUMSTANCES OF THE DEATH
On 8 July 2017 Michael Vukovic, who was suffering psychosis, jumped from a 2™ or 3
floor balcony and suffered a fracture to the L1 vertebra. He was admitted to Queen
Elizabeth Hospital where he suffered a cardiac arrest which caused hypoxic brain
damage. He was transferred to Kings College Hospital where he died on 11 July 2017.
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. —
At the inquest evidence was given yi who was at that time a consultant
psychiatrist at Oxleas.
On 14 March 2017 Mr Vukovic had been admitted to Oxleas under s2 MHA. He was not
previously known to services and this was his first psychiatric admission. He was
expressing paranoid psychotic symptoms. He was discharged from section on 27 March
2017 and he returned home. Prior to discharge he had been assessed by the Early
Intervention Service (EIS) but was considered to be ineligible for their service. He was
then referred to the Home Treatment Team (HTT) and to Lifeline (a drug and alcohol
service). The presumptive diagnosis was that the psychosis was drug/alcohol related,
but the evidence was that this couid only be confirmed after he had remained abstinent
for a period of 4-6 weeks; there was still a possibility that this was a primary psychosis.
My specific concerns are as follows:
(1) HR <visere was that Mr Vukovic was referred to the Home Treatment
eam Dut was never in fact seen by that team.
(2) The referral to Lifeline required Mr Vukovic to make the initial contact himself.
He did not do so, and Oxleas did not check whether or not he had done so. The
evidence was that if he had been under the care of the HTT he would have been
encouraged to engage with Lifeline.
(3) The result was that Mr Vukovic was discharged from hospital without follow up.
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and | believe you or your
organisation has the power to take such action.
YOUR RESPONSE
You are under a duty to respond to this report within 56 days, namely by 30 March 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
I have sent a copy of my report to the Chief Coroner and to the Mr Vukovic’s parents as
Interested Persons. | have also sent it tol f the Metropolitan Police who
investigated the death and may find it useful or of interest.
| 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.
29 January 2018 Philip Barlow
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.
Oxleas NHS apt OVING WES NHS Foundation Trust 28h March 2018 Pinewood Pinewood Private & Confidential Mr Phillip Barlow Deputy Coroner ante ae pave 01322 625 727 mraranncomermeme a5 APR aye Websile: www.oxleas.nhs.uk lerk to oroner Southward Coroner’s Court 1 Tennis Street Southwark SE1 1YD Dear Mr Barlow E RE: Preventing Future Death report touching the death of Michael Vukovic case ref: 01925/2017 Thank you for your letter of 02 February 2018, received on 06 February 2018 and requiring a response by 30 March 2018. le The Deputy Coroner P Barlow identified concerns and requested details of actions that were being taken to address these. Each matter of concern is addressed in turn: (1) Dr Apio’s evidence was that Mr Vukovic was referred to the Home Treatment Team but was never in fact seen by that team. Our local investigation carried out using route cause analysis methodology found that in fact Mr Vukovic had not been referred to the Home Treatment Team. This seems reasonable as there had been no self-harm as part of his admission, he engaged well on the ward and Mr Vukovie and his family were involved in the care | plans. He was discharged to the family home. (2) The referral to Lifeline required Mr Vukovic to make the initial contact himself. He did not do so, and Oxleas did not check whether or not he had done so. The evidence was that if he had been under the care of the Home Treatment Team he would have been encouraged to engage with Lifeline. Although Mr Vukovic was on a Greenwich ward, he had a Bexley GP. Lifeline would therefore have not been able to provide support. The support worker form Lifeline who visited Mr Vukovic on the ward provided him with the details of Pier Road. Pier Road is a service external to Oxleas that supports Bexley residents with drug and alcohol issues. The crux is with this and other similar services on the individual to engage. (3) Mr Vukovic was discharged from hospital without follow up. Mr Vukovic had a diagnosis of mental and behavioural disorder due to use of alcohol. He was not prescribed any ongoing antipsychotic medication, the early intervention in psychosis assessment concludes that his psychotic symptoms and hallucinations occurred as a result of alcohol withdrawal and this is supported by his quick recovery following detox. He was discharged to a family who had been involved in his care and treatment and who knew how to access crisis support if required. | hope that my response has addressed your concerns. Yours sincerely Helen Smith Acting Chief Executive
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