Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0052, written 13 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 | 13 Feb 2018 |
|---|---|
| Reference | 2018-0052 |
| Deceased | Natasha Ford |
| Coroner | Zafar Siddique |
| Coroner area | Black Country |
| 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 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Hospital Director, Raglan House. 2. Chief Executive, Cambian Group. 1 CORONER I am Zafar Siddique, Senior Coroner, for the coroner area of the Black Country. 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 the 27 September 2017, I commenced an investigation into the death of Ms Natasha Ford. The investigation concluded at the end of the jury inquest on 24 January 2018. The conclusion of the inquest was a short narrative conclusion of: Taking all of the evidence into account, the jury believe the cause of Natasha Ford’s death; by placing a plastic bag over her head, secured by a shoelace, to be misadventure causing her to pass away on the 20th September 2017 The cause of death was: 1a Hypoxic Brain Encephalopathy Asphyxial Cardiac Arrest b Suffocation c 4 CIRCUMSTANCES OF THE DEATH i) Miss Ford was a previous patient at Raglan House in Smethwick which is a 25 bed mental health hospital designed to provide an environment which promotes mental health recovery for women. ii) She was readmitted to Raglan House on 4th May 2017 under Section 3 of the Mental Health Act 1983 (amended 2007). She struggled to live independently and her condition declined. iii) Ms Ford had a complex medical history and a diagnosis of: • Borderline type of Emotionally Unstable Personality Disorder • Asperger’s Syndrome (Autism Spectrum Disorder, high functioning) • Dependent and Anxious/Avoidant Personality Traits • Substance Misuse iv) During her stay she exhibited volatile behaviour initially and with the 1 [IL1: PROTECT] support of staff she began to make progress. There were incidents of self harm and also evidence of aggressive behaviour. v) On the 19 September 2017 at around 02.30am, she found in her room with a plastic bag over her head which had been tied round using shoe laces. She was taken to City Hospital in Birmingham and despite medical treatment she sadly died on the 21 September 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. – 1. Evidence emerged during the inquest that there was a previous incident on the 27 July 2017 where she had placed a plastic bag over her head. Plastic bags were then restricted for a short time and then blanket restrictions were removed. This was due to a change in policy in procedure and in line with reducing restrictive practice policy and procedure. 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. 1. I note that blanket restrictions to access plastic bags to safeguard patients have now been revisited and the policy updated to reflect this from October 2017. However I have concerns that it still remains unclear the length of time blanket restrictions will remain in place and national guidance suggests that monthly reviews should take place. 2. You may wish to consider further reviewing the guidance and also confirm for all patients items are restricted whether plastic bags and similar notwithstanding their individual risk assessments. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 9 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; Family. 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 2 [IL1: PROTECT] response, about the release or the publication of your response by the Chief Coroner. 9 13 February 2017 Mr Zafar Siddique Senior Coroner Black Country Area 3 [IL1: PROTECT]
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.
VT Eehaviourai HealTh 73rd March 2018 The Senior Coroner Black Country Coroners Court Jack Judge House Halesowen Street O1dbur West Midlands B69 2AJ Dear Sir Inquest into the death of Natasha Ford — Regulation 28 report ith reference to the Regulation 28 report to prevent future deaths that you made following I vJite the Inquest into the death of Ms Ford. The contents of this letter has been approved by the Chief Executive of CAS Behavioural Health. You ha e expressed concerns in section 5 of your report on the basis of the evidence you heard at the Inquest “that there was a previous incident on 27 July 2017 where [Miss Ford] had placed a plastic bag over her head. Plastic bags were then restricted for a short time and then blanket restrictions were removed. This was due to a change in a policy in procedure and in line with Reducing Restrictive Practice Policy and Procedure”. in her evidence at the inquest on behalf of CAS Behavioural Health As stated by Ms and as reflected in the report that she provided to you for the purposes of the Inquest, at the time of the incident in July 2017 risk items were then restricted and removed from Ms Ford’s possession but later reintroduced once the Clinical Team assessed the risk as having reduced. This was in accordance with the CAS Policy and Procedure on Reducing Restrictive Practice in place at the time. this Policy reflecting the relevant provisions of the Mental Health Act Code of Practice that provides at chapter 26.37 that restrictions: • • • be used for no longer than necessary to prevent harm to the person or to others; be a proportionate response to that harm, and be the least restrictive option. After the incident on 19 September 201 and the subsequent sad death of Ms Ford. C.AS Beha\ ioural Health re ie ed the approach taken in its Polic and Procedure on Reducing In doing so, it has taken into account guidance published b the Care Quahty Restricthe Practice. Commission entitled “Brief Guide’ The E se of “Blanket Restrictions” in Mental Health Wards”. Whilst the CQC Guidance adopts the approach of the \lental Health Act Code of Practice. it does ackno ledge that all mental health inpatient sen ices hake some prohibited or “contraband” items and that certam prohibited items, including plastic bags, should not he challenged b the QC for breaking the approach to blanket restrictions in the Code of Practice. Raglan House, Raglan Road, Smethwick, B66 3ND C C C5C589 C E 53 C — C r a’ —— r r Behav ural HealTh Follo ing the review of the re1e ant Policy. CAS Behavioural Health has introduced a blanket policy restricting the use of plastic bags in all their hospitals. This Policy was put in place in October 2017 and a copy is enclosed. As a result of this Policy, no patients in any CAS hospitals are permitted to hae access to plastic bags in hospital. This applies to all patients. notithstanding the risk assessments undertaken in respect of each patient. location that All patients in hospitals operated by CAS Behavioural Health have in place a reducing restrictive practice plan that is reviewed monthly for the individual patients. There is a similar plan for the is reiewed three monthly. These plans detail why the relevant hospital/unit restrictions imposed on patients are necessary and what actions are being undertaken to reduce the restrictions. Again, this reflects the approach of the Mental Health Act Code of Practice, but I must it does not apply to the use of plastic bags as these are nov emphasise that. as stated abo’e. restricted by ay of a blanket policy. CAS Beha ioural Health intend to maintain the blanket ban on plastic bags in all their hospitals. CAS Behavioural Health and i, on behalf of Raglan House. consider that this fully addresses the concerns that you expressed in your Regulation 28 report. Floeer, if you have any further questions, please do not hesitate to contact me. Yours sincerely hospital Director Raglan House ai House R gin RoadSrnet[w B66 3ND
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