Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0136, written 27 Apr 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 Apr 2018 |
|---|---|
| Reference | 2018-0136 |
| Deceased | Katy Roberts |
| Coroner | Lorna Tagliavini |
| Coroner area | London Inner (South) |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths · Child Death (from 2015) |
| 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 THIS REPORT 1S BEING SENT TO: 1. South London & Maudsley NHS Foundation Trust (SLAM) 2. ER 200 Stect & Shamash Solicitors 3. Southwark Safeguarding Children Board 4. The Chief Coroner CORONER ! am the assistant coroner for the coroner area of Inner London South 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. INVESTIGATION and INQUEST On 11/10/2017 an investigation was opened into the death of Katy Roberts aged 16. The investigation concluded at the end of the inquest on 12/04/2018. The conclusion of the inquest was suicide. CIRCUMSTANCES OF THE DEATH Several years before her death, Katy was diagnosed with Asperger’s Syndrome, PTSD with a history of Anxiety, Depression and an eating disorder and was under the care of the Child and Adolescent Mental Health Service (CAMHS) at SLAM at the time of her death. In around May 2017, the care plan that had been formulated and notified to Katy Katy and her family, it was not confirmed in writing and little, if any opportunity was provided to appeal this decision to alter Katy’s care plan, despite the family’s increasing concerns over its appropriateness for Katy. Consequently, at the time of her death Katy was under a care plan believed by the family to be unsuitable for her, thereby exacerbating a breakdown of trust on the part of Katy’s family in the service provided by CAMHS/SLAM and creating a lack of provision for care or advice when a crisis, due to unexpected circumstances arose. in writing was significantly altered. Although this change was communicated orally to: CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern, although many of these were addressed in an investigative report prepared by SLAM. However, in my opinion a continued failure to clearly communicate changes to a care plan and provide a clear route to challenging or appealing these changes, together with the provision of details of all avenues for seeking emergency and non-emergency care and advice, create 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) Failure to communicate in writing a Care Plan and changes to it. (2) Failure to provide a clear route or opportunity to challenge or appeal these changes to the Care Plan. (3) Failure to expressly communicate in writing all routes by which, to raise concerns and seek help on a non-emergency or emergency basis. ACTION SHOULD BE TAKEN In my opinion action should be taken fo prevent future deaths and | believe your organisation has 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 22/06/2018 although |, 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 and ind to Southwark Children Safeguarding Board as Katy was under 18 at the time of her death. | 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, 27/04/2018 SIGNED BY CORONER: Li Tagliavini
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.
South London and Maudsley NHS) NHS Foundation Trust 6" July 2018 PRIVATE & CONFIDENTIAL Director of Nursing Trust HQ 1°‘ Floor, Maudsley Hospital Denmark Hill Camberwell London SE5 8RG Tel: 2032282033 Clerk, London Inner South Coroner for Inner South District Greater London Southwark Coroners Court 1 Tennis Street Southwark London SE1 1YD Dear Mr Thompson Re: Prevent Future Deaths Report for KR We would like to begin by reiterating our deepest sympathy to Katy’s family and to assure her family and the Court that we will learn all that we can from this event. Both the Coroner and our Serious Incident investigation found areas where our service should have been better. The Coroner raised some specific matters of concern, as follows: 1. Failure to communicate in writing a Care Plan and changes to it. 2. Failure to provide a clear route or opportunity to challenge or appeal these changes to the Care Plan. 3. Failure to expressly communicate in writing all routes by which to raise concerns and seek help on a non-emergency or emergency basis. We propose to address these concerns as follows: 1. Written Care Plan All CAMHS community practitioners, working with Young People with complex mental health difficulties, will complete a Community Care Plan with the Young Person concerned. While this has been our practice for some time, we have not adopted a consistent way of writing and sharing care plans and risk assessments. The Trust completed the testing of the Community Care Plan in June 2018 and CAMHS is now developing an implementation plan for its introduction across community teams. A Community Care Plan summary document is attached with this response. Monitoring of implementation and communication of the plans, at individual practitioner and team leader level, will be enabled by patient level, team based reports and supervision. CAMHS Borough Community Services will include this new 1 requirement in their monthly Performance Meetings and progress will be reviewed at the CAMHS Directorate Operational Governance meeting each Quarter. 2. Young Person’s Engagement A striking element of the Coroner's finding was the extent to which, whilst there had evidently been good communications between professionals involved in Katy’s care, there were opportunities missed to hear Katy’s thoughts and views. CAMHS community practitioners will ensure that the Community Care Plan proposed is reviewed by the Young Person and their family and then either agreed, or changed, within 4 working weeks. The number of Community Care Plans changed, following challenge or appeal will be audited and performance considered by CAMHS Directorate Operational Governance meeting each Quarter. 3. Guidance to Young People, their Parents and Carers All CAMHS community services provide clear written guidance to Young People, their families and other agencies on how to seek help from CAMHS and other services. We will remind all staff to make this information available routinely and will conduct a survey with service user, carers and parents in January 2019 to assure the CAMHS Directorate operational management teams that the information is being made available. Southwark now has an Emergency and Developing Crisis Protocol, which has been widely shared with GPs, schools counsellors, Young People and their families; a copy is attached. Yours sincerely Beverley Murphy Director of Nursing
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