Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0130, written 3 May 2018. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 3 May 2018 |
|---|---|
| Reference | 2018-0130 |
| Deceased | Martin Baker |
| Coroner | Andrew Cox |
| Coroner area | Plymouth, Torbay and South Devon |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Avon and Wiltshire Mental Health 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.
for Plymouth Torbay and South Devon REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Dr A Morris, Chief Executive Officer, Livewell South- west, Windsor House, Tavistock Road, Plymouth, PL6 5UF CORONER | am Andrew James Cox, Assistant Coroner for Plymouth Torbay and South Devon. 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. http://www. legislation. gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www. legislation.gov.uk/uksi/2013/1629/part/7/made INVESTIGATION and INQUEST On 9 September 2016, | commenced an investigation into the death of Martin Glyn Baker, then aged 48. The investigation concluded at the end of the inquest on 19 April 2018. The conclusion of the inquest was prescription drug-related death. It is likely Mr Baker suffered from a slow metabolism which caused potentially toxic levels of venlafaxine, prescribed to him, to build up. Together with a deteriorating physical condition and mild myocardial scarring found at post- mortem, it is likely this induced a fatal cardiac arrhythmia. The medical cause of death was given as 1a) drug toxicity CIRCUMSTANCES OF THE DEATH Mr Baker suffered with mental health issues for over 20 years. He had previously attempted suicide on a number of occasions. After a failed attempt to take his own life following a jump from height he fractured his spine and was left confined to a wheelchair. Psychiatric support for Mr Baker was provided through Livewell South-west and I heard at inquest | — both of whom saw the deceased. Prior to the deterioration in Mr Baker's condition that led to his demise, had decided to stop a prescription of lithium. This was as a consequence of excessive thirst complained about by Mr Baker which, in turn, led to the consurgatiggsof a large number of fizzy drinks and resulted in problems with urinary nconnencofhliam unaware, at the time of his decision, that there had been earlier failed attempts to stop the lithium prescribed to Mr Baker i 2s also unaware that Mr Baker had signed a form of consent authorising Livewell South-west to discuss care arrangements made for him with his family. 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. — [BRIEF SUMMARY OF MATTERS OF CONCERN] (1) It was accepted in evidence that there had been a lack of communication with the family. They had not been involved in any psychiatric reviews instead, on one occassion, a consultant was left to rely upon information provided by a junior healthcare assistant. At inquest | expressed my view that where a patient has signed a consent form authorising discussion of relevant 1 Derriford Park, Derriford Business Park, Plymouth, PL6 5QZ Tel 01752 204636 | Fax events with the family, the default position should be that there will be involvement of the family in the absence of any good reason not to do so, for example, a patient's subsequent express instruction not to share something with the family. In this case the family were unaware that Mr Baker had been discharged from psychiatric support and were unaware of what to do in the event of deterioration in Mr Baker's condition. (2) It was also accepted in evidence that at the time of these events there was a shortage of care coordinators something described as “very far from ideal.” | was advised that this situation has now been corrected. Nevertheless, it was the clear view of the family, which | accepted, that in the absence both of a care coordinator and the involvement of the family there had been no one to act as an advocate on Mr Baker's behalf, something that had been to his detriment. (3) It was accepted in evidence b’ that his risk assessment failed to address periodic impulsivity that Mr Baker demonstrated. | found this was not causative of the death. Nevertheless, | felt this was a point of learning that may well have a bearing in the care of future patients and | felt it appropriate to bring it to your attention. ACTION SHOULD BE TAKEN wer In my opinion action should be taken to prevent future deaths and | believe you have the po' 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 1 July 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. COPIES and PUBLICATION of my report to the Chief Coroner and to the following Interested Persons lll | have sent a co) | 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. Signature for Plymouth To’ and South Devon Lt 1 Derriford Park, Derriford Business Park, Plymouth, PL6 5QZ Tel 01752 204636 | Fax
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.
© :;+ Bath & North East Somerset Council Bath and North East Somerset Clinical Commissioning Group Working together for health & wellbeing Adult Care & Health Commissioning Kempthorne House Mr lan M Arrow St Martin's Hospital Senior Coroner for County of Devon Clara Cross Lane 1 Derriford Park Combe Down, Bath BA2 5RP Derriford Business Park Plymouth . PL6 5QZ co aia epsite: www.batnnes.gov.u Date: 23 June 2018 Dear Mr Arrow Re: Martin Glyn Baker, DOB 30.03.68 Regulation 28: Report to Prevent Further Deaths In response to the outcome of this case and your Regulation 28 Report to Prevent Further Deaths a meeting was held between senior managers from Bath and North East Somerset Council (the B&NES Council) and Avon and Wiltshire Mental Health Partnership NHS Trust (the AWP Trust) to agree a joint approach to address the learning from Mr Baker's death. Within the Bath and North East Somerset local authority area mental health provision is delivered through integrated teams where AWP Trust and B&NES Council staff work alongside each other under a heads of agreement arrangement. However, B&NES Council acknowledges the request within the Regulation 28 Report for the Council to accept responsibility for responding to the recommendations made. An action plan to deal with each of the points in the Regulation 28 Report has been prepared by Karyn Yee-King, Principal Mental Health Social Worker for BRNES Council. This details how B&NES Council and AWP Trust will approach each of the points you identified. AWP Trust colleagues have contributed to the drafting of this plan and have agreed the final version. It specifies the actions that we will take in the B&NES local authority area, which agency will take the lead and provides a timeframe for completion of actions. Bath and North East Somerset - The place to live work and visit () + + Bath & North East Somerset Council Bath and North East Somerset Clinical Commissioning Group The action plan also incorporates additional learning not documented in the Regulation 28 Report. Finally, the plan also indicates how we will monitor the effectiveness of the changes made. Please find a copy of the action plan attached. | hope that the actions identified respond sufficiently robustly to the concerns identified in your report. Please do not hesitate to contact me regarding any further information you require or if you want a progress update report at a later stage. Yours sincerely Mike Bowden Corporate Director B&NES Council Bath and North East Somerset -7he place to live work and visit
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