Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0067, written 6 Mar 2018. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 6 Mar 2018 |
|---|---|
| Reference | 2018-0067 |
| Deceased | Rastislav Petrisko |
| Coroner | Andrew Harris |
| Coroner area | London Inner (South) |
| Category | Mental Health related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
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
THIS REPORT IS BEING SENT TO:
4, Mr Ben Travis, Chief Executive, Oxleas Mental Health Trust, Pinewood
House, Pinewood Place, Dartford, Kent DA2 7WG
CORONER
Iam Andrew Harris, Senior Coroner, London Inner South jurisdiction
CORONER’S LEGAL POWERS
I make this report under paragraph 7, Schedule 5, Coroners and Justice Act 2009
and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.
INQUEST
I opened an inquest into the death of Mr Rastislav Petrisko, who died on
16.04.17 in University Hospital Lewisham;{Case Ref: 01106-17 JB).
Tt was concluded on 28" February 2018. The medical cause of death was:
la Use of morphine and cocaine, exacerbated by alcohol intake
The conclusion stated that he died from an overdose of drugs but the jury could
not be sure beyond all reasonable doubt that he intended for the act to end his
life.
CIRCUMSTANCES OF THE DEATH.
He was a man with a personality disorder, homeless and isolated from family
abroad, with a history of drug and alcohol misuse and chronic negative thoughts
of suicide. He only injected heroin as part of his plan to kill himself. He had
fifteen in-patient admissions to a mental health ward between May 2015 and April
2017, many were after genuine suicide attempts. He was admitted on 1* April
under section 2 of Mental Health Act, having tried to kill himself with drugs and
was angry to have been resuscitated. On 15" April, he was verbally abusive and
agitated after homophobic comments of another patient, but calmed before being
given leave which he used to return to a car park which was used by drug users and
from which he had been admitted twice before. There he again took an overdose
of drugs. He was attended by emergency services at 22.32, after being called by a
passer-by and was still alive but was not able to be resuscitated.
The jury found that he died in part due to his on-going lack of engagement with
statutory services. His low risk assessment before given leave on 15" April seemed
unsuitable and contributed to the delay of the ward in notifying the police, when
Ratislav Petrisko failed to return to the ward at 19.25, The jury recorded that the
decision to allow unescorted leave seemed inappropriate and the risk to himself
was not recognised.
CORONER’S CONCERNS
During the course of the inquest, the evidence revealed a matter giving tise to
concern that in my opinion means that there is still a risk that future deaths will
occur unless action is taken. In the circumstances it is my statutory duty to report
to you.
The MATTER OF CONCERN is as follows. -
The responsible clinician (RC) assessed the patient as low risk on granting an
hour’s unescorted leave in the local area from 13th. He said that he was not
mentally unstable, which would trigger an escort. He was no longer expressing
suicidal thoughts. The RC did not consider that Mr Petrisko was an immediate
risk to himself, although the past medical history established a higher long term
risk. He had already taken leave several times without self-harming (although
unknown to the doctor he had returned drunk on 8" whilst in another unit).
Although there was reference to recent or pending drug testing there was no
record of the result of any drug screening on return from leave in this admission.
A nurse indicated that being high risk made no difference to the likelihood of
drug screening and the RC indicated that he may still be given leave if he was high
tisk, However a mental health nurse on the ward said that he was given leave as he
was low risk. The risk assessments were guided by the statutory guidance of the
Mental Health Act and were not subject to further local guidance. In retrospect
the RC did not change his risk assessment.
A missing persons form was completed by the ward. His risk was described as
concern he would take large amount of drugs and alcohol, which would affect his
mental state and that it was not out of character. In answer to the question
whether he was likely to commit suicide, was written: “Was admitted with
overdose cocaine and medication with suicidal intent”. The police were called at
21.56 and attended at 23.30, by which time emergency services were already in
attendance to him in the car park, following a 999 call.
As he was low risk the local policy on handling patients who had absconded at the
time indicated that he could be given a period of grace before the police were
notified, if he did not return at the allotted time. This was given as he had a
history of being late back from leave. The ward notified the police 1 hour 49
minutes after he was due back, a period of time acknowledged to be too long. The
policy in place made clear that a high risk patient should be reported immediately.
The revised Trust policy continues that requirement, removes the period of grace
but leaves it to the discretion of the clinicians when to call the policy, if the patient
is deemed not to be high risk.
The Di from the Metropolitan Police Service indicated on reviewing the case, that
he would be classed as medium risk, not low risk. High risk is an immediate risk to
life, when a DI is deployed immediately to investigate and search. Medium Risk is
that the risk to life is not immediate, but is a concern. An investigation and search
is begun within the hour. Low risk is where there are no immediate concerns, The
investigation may not begin straight away but take a few days.
She further said that an immediate action would be to identify the places from
which he had been admitted before. The medical records indicated that of the last
three admissions he had been brought in from the Calderwood Street Car Park on
two occasions (13.12.16 and 05.01.17). That was the site where he took the final
fatal overdose.
Thus if the police had been rung immediately, and assuming they took no action
for the whole of the first hour, they would have had at least 49 minutes to find
him in this site, which on the facts of the present case would enable an inference
to be drawn that his life would have been saved. Thus the risk assessment by the
police would seem to enable some deaths to be prevented, which would not
necessarily on application of the assessment of the responsible physician, as
immediate reporting only occuts if the patient is high risk. It is of concern that
there are two different methods of assessing the risk when a vulnerable patient is
granted leave, both in operation, one with greater potential of saving his life than
the other.
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths. I believe that the
NHS Trust has the power to take such action.
I recognize that to do so may involve other organizations. I am therefore copying
this to the Metropolitan Police Service and Royal College of Psychiatrists and
attaching Oxleas Procedure for missing /absconding patients who are absent
without leave, version 3.2.
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this
report, namely by Monday April 30", 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.
If you require any further information or assistance about the case, please contact
the case officer,
COPIES and PUBLICATION
I have sent a copy of my report to the following Interested Person:
Mother
I am also sending this report to the following, who may have an interest:
Metropolitan Police Service
Royal College of Psychiatrists
Tam 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.
[DATE] [SIGNED BY CORONER]
96-03-1
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