Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0039, written 9 Feb 2018. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 9 Feb 2018 |
|---|---|
| Reference | 2018-0039 |
| Deceased | Gail Bannister |
| Coroner | Andrew Cox |
| Coroner area | Worcestershire |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. 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. Sarah Dugan, Chief Executive, Worcester Health & Care Trust
1
CORONER
I am Andrew Cox, Assistant Coroner for the coroner area of Worcestershire
2
CORONER’S LEGAL POWERS
I 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 20/9/17, I commenced an investigation into the death of Gail Ann Bannister then
aged 60.
The investigation concluded at the end of the inquest on 8 February 2018.
The conclusion of the inquest was suicide, the medical cause of death being 1a)
hanging.
4
CIRCUMSTANCES OF THE DEATH
Mrs Bannister had a long history of a fluctuating mental health condition. In March 2017,
she was noted to suffer a deterioration following the illness and subsequent death of her
father. She was seen by her GP and then referred to CARS and onto the HTT service.
She was referred back to CARS in early August 2017. A Care Co-ordinator had been
appointed on 20 July to facilitate psycho-social services that it was felt Mrs Bannister
required and to provide continuity in her care. Her care co-ordinator did not see her
between the date of her appointment and Mrs Bannister's death two months later.
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. –
(1) The rationale behind discharging Mrs Bannister from the HTT to CARS was that she
had been seeing too many different people. It was felt that by concentrating her care in
the hands of the community consultant psychiatrist and a Care Co-ordinator, who would
arrange the psycho-social services she would benefit from, this would improve her
treatment. The fact that the care co-ordinator did not see her frustrated and undermined
this approach.
(2) During the inquest I was told that the deceased's husband tried to speak to members
of the care team who were based at the Studdart Kennedy centre when a crisis
developed. It took him several hours to get through. I was told there is only one phone
line and that this is a known and recurring problem.
1
6
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe you have
the power to take such action.
.
7
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report,
namely by 6 April 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
I have sent a copy of my report to the Chief Coroner and to the following Interested
Persons:
, husband of the deceased
I 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.
9
Signed
--------------------------------A J COX--------------------------------------------------------------
A J Cox
9 February 2018
HM Assistant Coroner
2
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.
INHS) Worcestershire Health and Care NHS Trust Chief Executives Office Worcestershire Health and Care NHS Trust Isaac Maddox House Shrub Hill Road 27 March 2018 Worcester WR4 SRW Mr A Cox HM Assistant Coroner Tel: 01905 681667 Worcestershire Coroner's Court e-mail: rs The Civic ; Martin's Way www. hacw.nhs.uk Stourport-on-Severn Worcestershire DY13 8UN Dear Mr Cox Re: Inquest touching the death of Gail Bannister Regulation 28 report to prevent future deaths - response Thank you for your letter dated 9 February 2018, and the enclosed Regulation 28 report, | have read your report with great care and note the concerns that you have raised as a result of the coronial inquiry into the death of Gail Bannister. In your report, you highlighted the following points of concern and | will respond to each in turn: 1) The rationale behind discharging Mrs Bannister from the HTT to CARS was that she had been seeing too many different people. It was felt that by concentrating her care in the hands of the community Consultant Psychiatrist and a Care Co-ordinator, who would arrange the psycho-social services she would benefit from, this would improve her treatment. The fact that the Care Co-ordinator did not see her frustrated and undermined this approach. It was the expectation of both the discharging clinicians, and the community Psychiatrist that a Care Co-ordinator would be frequently involved with Mrs Bannister. This is also documented in the plan of care set out by the community Psychiatrist following her appointment with Mrs Bannister on 16th August 2017, when the Care Co-ordinator was also in attendance. As heard in evidence during the inquest, the Psychiatrist was under the impression, that following this appointment, weekly visits from the Care Co-ordinator were in fact taking place. It is extremely concerning that it transpires that, with the exception of the above mentioned joint appointment on 16th August 2017, no contact was made by the Care Co-ordinator with Mrs Bannister. | confirm that the Trust is addressing this matter in an appropriate manner, | am sure that you will appreciate the confidentiality obligations which | face, which means that | am unable to share specific details with you and other Interested Persons. Chairman: Chris Burdon Chief Executive: Sarah Dugan Working together for outstanding care 2) During the inquest, | was told that the deceased's husband tried to speak to members of the care team who were based at Studdart Kennedy House when a crisis developed. It took him several hours to get through. ! was told that there is only one phone line and that this is a known and recurring problem. An action plan has been put in place to install a telecommunications system which will provide a digital telephone system (VOIP). This will enable call waiting and call forwarditransfer automatically, An initial review of the current system has already taken place and a contractor survey of Studdart Kennedy House has been agreed and funded by Worcestershire County Council (who own the building). This costings survey was undertaken on 21st and 22nd March 2018, however has not yet been received by the Trust. It is hoped that a capital bid will be completed by the end of April 2018 and sent to the Finance Director for approval, with work to the begin following this. Unfortunately, a date for completion cannot yet be given as this will depend upon external contractors, however, | would like to offer re-assurance that this matter is being given the attention required. In the meantime, interim measures have been implemented, consisting of a mobile telephone being used by Adult Mental Health staff to use to contact the site/duty worker and communication has been given to all staff to advise them of this interim measure and the appropriate contact telephone numbers to use. ! trust that the foregoing has adequately addressed the Regulation 28 report issued subsequent to the inquest into the death of Gail Bannister. Should you require any progress updates or clarification in relation to this matter, please do not hesitate to ask. | confirm that | have not forwarded a copy of this response to any other Interested Person and would therefore be grateful if you could do so as appropriate. | also confirm that the Trust is content for both the regulation 28 report and the response to be released or published should the Chief Coroner wish. Yours sincerely \ Sarah Di Chief Executive Chairman; Chris Burdon Chief Executive: Sarah Dugan Working together for outstanding care
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