Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0134, written 8 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 | 8 May 2018 |
|---|---|
| Reference | 2018-0134 |
| Deceased | Joanne Richardson |
| Coroner | Rachael Griffith |
| Coroner area | Dorset |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Dorset Healthcare University NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
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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. Mr Ron Shields, Chief Executive of Dorset Healthcare University NHS Foundation Trust, 4-6 Sentinel House, Nuffield Industrial Estate, Poole BH17 ORB CORONER I am Rachael Clare Griffin, Senior Coroner, for the Coroner Area of Dorset. 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. INVESTIGATION and INQUEST On the 4 October 2017, an investigation was commenced into the death of Joanne Elizabeth Richardson, born on the 3" February 1962. The investigation concluded at the end of the Inquest on the 25% April 2018. The Medical Cause of Death was: la Hanging The conclusion of the Inquest was suicide. CIRCUMSTANCES OF THE DEATH On the 26th September 2017 the deceased, who was known to suffer with mixed anxiety and depressive disorder, was found suspended by a ligature which was attached around the leg of a bed and passed through the bannister of the staircase at her home address at 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. During the inquest evidence was heard that: vi. vii. Mrs Richardson was under the care of the Dorset Healthcare University Foundation Trust (DHUFT) in relation to her mental health. Her latest period of treatment began in June 2017. She was under the care of the Community Mental Health Team (CMHT) from that time until the time of her death on the 26% September 2017. The CMHT had referred her to the West Dorset Steps to Wellbeing Service for therapy. She was assessed by the Psychiatrist from the CMHT on the 13% July 2017, 8 August 2017 and 23" August 2017. The Psychiatrist left the Trust and her case was then managed by a Nurse Prescriber who assessed her on the 19 September 2017. During these assessments, her risk of harm was deemed to be low. She was reviewed by the Steps to Wellbeing Service on the 21% August 2017 when she was in low mood and had thoughts, but no plans, of ending her life. The team felt that her risk was too high for treatment by the Service and they therefore intended to refer her back to CMHT. Mrs Richardson was only advised of this in writing in a letter dated the 21% September. The details of that assessment were never referred to the CMHT. They were therefore not aware of how she presented or the risk assessment made by the Steps to Wellbeing Service. This information could have been very valuable to those in the CMHT who assessed her on the 23 August and 19" September. Evidence was given that some of the Steps to Wellbeing Service have access to DHUFT records, namely RIO records, but not all of them do. Evidence was further given that they do not write entries in these records. Those carrying out assessments therefore are not likely to have access to all information available to DHUFT in relation to the patient. Further on the 28" August 2017, Mrs Richardson contacted the Crisis Team within DHUFT stating that she had suicidal thoughts of ending her life by hanging. A call was made from the Crisis Team to the CMHT and a Community Psychiatric Nurse was spoken to. There was however no follow up after this, or any written communication with anyone involved in her care. Valuable information therefore, in relation to a patient, is not being communicated to those involved in the care. There does not appear to be joined up working between the different teams within the Trust. This could therefore lead to inaccurate risk assessments and a future death. 2. Ihave concerns with regard to the following: i. That there is a lack of communication between the different teams in DHUFT in respect of a patient’s care and as a result there could be the death of a person in the future. ii. I would therefore request that there is a review of the policies by DHUFT in relation to the communication between the different teams within DHUFT, particularly between the CMHT and the Steps to Wellbeing Service. ACTION SHOULD BE TAKEN In my opinion urgent action should be taken to prevent future deaths and I believe you and/or 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, 3" 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 I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: (1) Pe: Richardson’s husband 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. Dated Signed f (Backes — Rachael C Griffin st" May 2018
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 Dorset HealthCare University NHS Foundation Trust Corporate Department Sentinel House Nuffield Road Poole Dorset BH17 ORB Tel: 01202 277003 www.dorsethealthcare.nhs.uk Private and Confidential Mrs Rachael C Griffin HM Senior Coroner for Dorset The Coroner’s Office for the County of Dorset Town Hall Bournemouth 27 June 2018 BH2 6DY Your Ref: RCG/02814-2017/SD Dear Mrs Griffin Re: Inquest touching the death of Joanne Elizabeth Richardson (deceased) | write to you further to the above mentioned Inquest which concluded on 25th April 2018 when you raised concerns and the Regulation 28 Report dated 8th May 2018. You raised three concerns. The first concern was that, critical patient information between the Trust's Steps to Wellbeing Service (S2VW) in West Dorset and the Trust's Community Mental Health Team (CMHT) had not been shared. Secondly that patient information is recorded in two different electronic patient information systems and that not all staff have access or regularly review information in each of these systems. Thirdly that Mrs Richardson had not been followed up in a timely manner by the CMHT, after making contact with the Crisis Team. You requested a review of the policies regarding communication between teams, in particular between the CMHT and S2W. We have reviewed our processes and policies regarding communication and joined up working between CMHTs and S2W services alongside relevant legislation and guidance. Currently administrators check both electronic patient information systems — IAPTus for $2W for all referrals received by the CMHTs and Rio for S2W and CMHT teams to see if the patient is known to either service. Read only access for both systems are available to administrators and team leads. If the patient has a history with local mental health setvices, this information is copied by an administrator onto the S2W clinical notes and Better Every Day Our vision is to lead and inspire through excellence, compassion and expertise in all we do makes this available to the allocated assessing clinician, prior to them assessing the patient. After the assessment, a copy of the assessment letter (summarising presenting problems, agreed treatment plan, risk summary) is copied to the other teams who are involved with the patient. Any significant changes to the treatment plan that take place during contacts with teams are communicated to the other teams involved. it is also standard practice that at the point of discharge, for a patient who is under the care of both services for a discharge letter to be sent to the other team and GP. We have reinforced the expectation that, when a patient is being seen by both teams, a discussion is had between S2W and CMHT clinicians, prior to discharge to agree an appropriate discharge plan. Furthermore, we have reinforced the expectation that treatment decisions are communicated to patients face to face or over the telephone in order to allow collaboration and feedback. These decisions can then be formalized in a written letter to the patient, but this should only happen after a discussion has been held with the patient and other team. In addition to the communication processes described above we introduced the following measures to aid closer working between teams. On IAPTus (S2W) a label has been identified that will be a visual aid on the personal information page of the record indicating that a patient is also known to the CMHT. The Rio (CMHT) system does not have this functionality. However, a report has been developed that identifies patients who are under the care of both services. if there is a significant change to a client’s risk, indicating that there is a significant risk of harm, the allocated clinician will share this information with the other service in a timely manner, by telephone in the first instance. If it has not been possible to speak via telephone then this information will be shared via email using the team referral inbox that is screened daily. This will be used to share urgent information pertaining to a client's risk and then be uploaded to Rio or IAPTus respectively. The CMHT hold weekly multidisciplinary team meetings to review cases. A S2W practitioner is able to phone into a set slot at a CMHT / team meeting. This enables case discussions and review of risks for those people who are under the care of both services. Any discussions will be documented in the CMHT team meeting minutes and both clinical systems. With regard to your concern about timely follow-up, our Crisis Teams inform CMHTs by email when they have had contact with one of their patients. The Root Cause Analysis review highlighted that there was a failure to record the CMHT assessment and care plan in response to receiving information about Mrs Richardson’s contact with the CHTT. Better Every Day Our vision is to lead and inspire through excellence, compassion and expertise in all we do Emails from the CHTT are sent to CMHT clinicians involved in the patient’s care and to a generic CMHT account that is monitored by the administration team. They ensure that a clinical member of the team is aware of the message. The need to act on such information and to document decisions on the electronic record has been reinforced within the CMHT involved through discussion of this omission in care. This learning has been disseminated to all CMHTs across the Trust. | hope that the actions outlined provide assurance that the Trust has investigated this matter thoroughly, communicated this learning and new processes to staff, and introduced additional measures to ensure that communication of clinical and risk information between CMHTs and S2W in Dorset is reliable, clear and timely. If you have any queries at all, please do not hesitate to contact my office. Yours sincerely Ron Shields Chief Executive Better Every Day Our vision is to lead and inspire through excellence, compassion and expertise in all we do
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