Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0057, written 27 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 | 27 Feb 2018 |
|---|---|
| Reference | 2018-0057 |
| Deceased | David Ireland |
| Coroner | Lydia Brown |
| Coroner area | Exeter and Greater Devon |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Devon Partnership NHS Trust |
| 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 (1) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Melanie Walker Chief Executive Devon Partnership NHS Trust Wonford House Drydon Road Exeter EX2 5AF 4 | CORONER | am Mrs Lydia Brown, Assistant Coroner for the Exeter and Greater Devon District 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 21% February 2017 | commenced an investigation into the death of David John Ireland. The investigation concluded at the end of the inquest on 6'" February 2018. The conclusion of the inquest was Multiple Traumatic Injuries Conclusion — Accidental Death 4 | CIRCUMSTANCES OF THE DEATH David experienced an episode of acute onset psychosis and exhibited bizarre behaviour. He forced entry into a house on St James Road, Exeter and when detained in a first-floor bedroom by the residents, climbed out of the window and fell to the ground sustaining serious injuries. He died in Royal Devon and Exeter Hospital shortly after admission on 13 February 2017. 5 | CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concer. 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) Contact was made by Mr Ireland’s friend on the day of his death with the crisis team. Mr Ireland also spoke with them during the same telephone contact call. No advice was given that Mr Ireland could present at the emergency department should concerns continue about his mental health crisis. ; Had such advice been given it may have impacted on the course of events and facilitated an urgent mental health assessment. This opportunity was lost as Mr Ireland was not able to make any such decision and his friend was unaware that this was an option available with sudden onset mental health symptoms. ACTION SHOULD BE TAKEN in my opinion action should be taken to prevent future deaths and | believe you and your organisation 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 26% April 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 | have sent a copy of my report to the Chief Coroner and to the following Interested Persons: | 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 fo 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 respon th jef Cor Date 99 fesuiory Ce eae “a seseeevaeenenneensecaeenanenaveres H. M. Assistant Coroner for Exeter and Greater Devon Room 226 County Hall Topsham Road EXETER Devon EX2 4QD
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.
Devon Partnership INHS NHS Trust Trust Headquarters Wonford House Hospital Dryden Road Exeter EX2 5AF Ms L Brown HM Assistant Coroner Telephone: 01392 208866 Exeter and Greater Devon Coroner's Office Web: www.devonpartnership.nhs.uk Room 226 Devon County Hall Your Ref: LCB/SJ File No: 432 2017 Exeter Our Ref: STEIS 2017/4729 RMS 26205 EX2 4QD 28 April 2018 Dear Ms Brown Re: David John Ireland (deceased) ~ DOD 13/02/17 - Inquest 6 February 2018 Regulation 28 Report to Prevent Future Deaths Thank you for your letter of 27 February 2018 which we received on the 5 March 2018 following the inquest into the death of David Ireland. As an organisation we are committed to learning from these tragic events and have since receiving your report and recommendations taken the opportunity to share your findings with the service involved as well as across the wider trust. The Trust has undertaken a Root Cause Analysis Investigation following the death of David; the report was shared at the inquest. Your report contained the following matter of concern - (1) No advice was provided that Mr Ireland could attend the emergency department should concerns about his mental health continue Following review of your report and consideration of your recommendations | am can confirm that as described at the inquest it would be our expectation that any contact made with the crisis team should include describing the options available to service users, families and carers should concerns continue. These options depending on the severity of the concerns would include further contact with the crisis team (out of hours this would be dealt with by the single point of access team), contacting their general practitioner (or out of hours service) or attendance at an emergency department where there would be access to one of our Liaison Psychiatry Teams. We will be including specific reference to this concern in our next Trust wide ‘Safety Briefing’ which is made available to all staff, we have also asked for this concern to be raised with the relevant teams through their local learning from experience groups and equivalent forums. We would be happy to provide a copy of the Safety Briefing when it is available. We will be including the need to give this advice in our local induction for temporary workers (agency staff) within these teams. We have asked the relevant teams to review any answer machine messages they use and include appropriate reference to all sources of further support. Chair. JulieDent CBE - Chief Executive: Melanie Walker | hope that the actions described demonstrate our commitment to the learning we have undertaken and that the Trust is committed to this continued positive work within our services. If you require any further information please do not hesitate to contact me. Paul Keedwell RMN. BSc (Hons) Health Studies. Executive Director of Nursing and Practice Chair: JulieDent CBE - Chief Executive: Melanie Walker
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