Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0137, 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 | 2018-0137 |
| Deceased | William Dickens |
| Coroner | Henrietta Hill QC |
| Coroner area | London Inner (South) |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | South London and Maudsley NHS Foundation 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 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: (1) The South London and Maudsley NHS Foundation Trust (“SLAM”) (2) The Care Quality Commission Tam HENRIETTA HILL QC, Assistant Coroner, for the coroner area of Inner South District of Greater London. 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 WILLIAM DICKENS, then aged 77 years, died on 10 May 2017. An investigation into his death was opened and an inquest held from 1-4 and 8 i May 2017. The medical cause of Mr Dickens’ death was hanging. The jury 1 returned a narrative conclusion identifying a range of issues which they concluded had contributed to Mr Dickens’ death. 4 | CIRCUMSTANCES OF THE DEATH The circumstances of the death are as follows: | (1) Until late April 2017 Mr Dickens had no issues with his mental health. His family noticed a deterioration in his mental health at that point and he was prescribed medication by his GP. | | (2) On 9 May 2017 Mr Dickens tried to take his own life at his home by | wrapping a telephone cable around his neck. An ambulance was | called and he was taken to St Thomas’ Hospital. When there he was | classified as at “high” risk of repeat self-harm and kept on one to one observations. (3) He was transferred to the mental health unit for older patients at the Maudsley Hospital, run by SLAM. On arrival there he was again classified as at “high” risk of repeat self-harm. (4) Mr Dickens was placed on a regime of intermittent observations which meant he should be seen at varying intervals but at least every 15 minutes. (5) His property was searched and in breach of SLAM policy and recognised process his belt was returned to him. (6) Despite being on a regime of intermittent observations, Mr Dickens was not seen from 9.47 am until he was discovered hanging by a belt from the bed in his room just before 10.40 am. CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern, and I continue to consider that such matters exist. 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 that: (1) From 10 am on the morning of 10 May 2017 the observation regime for the ward was not complied with. While there are notes on the observation log suggesting that some patients had been seen in the period between 10 am and 11 am, Mr Dickens was not seen from 9.47 am until he was discovered hanging by a belt from the bed in his room just before 10.40 am. The observation log shows that several other patients were unaccounted for during the same period. (2) During the inquest the nurse in charge of the ward gave evidence that the entries she had made on the observation log for the period between 10 am and 11 am were not made contemporaneously but after Mr Dickens had died. No note had been made on the log to indicate that the entries were being made after the event. (3) While the observation log may have different purposes, it seems to me that two reasonable purposes of it are (i) to act as a prompt to make sure that the necessary checks on the patients were in fact conducted; and (ii) to ensure that there is a record that at a certain time, certain patients had been accounted for and were safe. (4) Those purposes are plainly frustrated if entries are made on the log at times that are different to the actual observations, and after the event. (5) Given that part of the purpose of the log is to ensure the safety of patients, particularly those such as Mr Dickens who are at high risk of self-harm or suicide, defects in the observation log process give rise to a concern that circumstances creating a risk of other deaths will occur, or will continue to exist, in the future. ACTION SHOULD BE TAKEN I consider that action should be taken to prevent the occurrence or continuation of such circumstances, or to eliminate or reduce the risk of death created by such circumstances. Accordingly, | am reporting the matter to you as I believe you may 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 4 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 T have sent a copy of my report to the Chief Coroner and the family of Mr Dickens who were an Interested Person in the inquest. Lam 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. Signed ....... Henrietta Hill OC ..scsssssssrersessosnesesesesesssssees Assistant Coroner
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 IY/ER3 NHS Foundation Trust Beverley Murphy Director of Nursing Trust Headquarters The Maudsley Hospital Denmark Hill London SE5 8AZ Tel: 020 3228 2606 Fax: 020 3228 2362 Ms Henrietta Hill QC Assistant Coroner Southwark Coroner's Court 1 Tennis Street, London SE1 1YD Wednesday, July 04, 2018 Dear Ms Henrietta Hill Re: Prevent future deaths Mr William Dickens This letter responds to the Prevent Future Deaths report issued to South London and Maudsley NHS Foundation Trust on 8! May 2018 in relation to the death of Mr William Dickens on 10" May 2017 whilst in our care. In the PFD report you set out five matters of concern that relate to how nurses. observed Mr Dickens, how and when the abservations were recorded and how effectively observations records are used to maintain the safety of Mr Dickens. You have directed the Trust to take action to eliminate or reduce the risk of death created by the way our nurses carried out and recorded observations for Mr Dickens. The actions we will take are: 1) The Director of Nursing to use the case as the basis of an internal safety alert ‘Blue Light Bulletin’ to be sent out to all registered nurses to reinforce the practice standards. To be completed by 6/07/18 2 — All Ward Managers to be directed to have a Jeaming conversation with inpatient registered and non-registered nurses about the practice. To be completed by 31/07/18 3) The Therapeutic Engagement and Observation Policy to be reviewed and particular attention to be paid to the clarity of practice standards and the implementation of the policy. ail AEE EEE Underway, to be completed by 31/08/18 4) From September 2018 the cohort of newly registered nurses to receive a "Learning the Lessons” presentation, using this case as the basis, of the importance of timely observation and recording in preserving safety and confidence in those we care for. Commencing September 2018 and annual thereafter. 5) From September 2018 the cohorts of nursing in training (year 1-3) to receive a Learning the Lessons presentation, using this case as the basis, of the importance of timely observation and recording in preserving safety and confidence in those we care for. Commencing September 2018 and annual thereafter. — 6) Report the PFD and the actions being taken to the Board of Directors as a part of the quarterly public learning lessons report. Completed by November 2018 7) The Director of Nursing as Chair of the E-observation Project Group. to develop the timeline for transforming mental health safety and engagement observations into the e-observation framework, This is a long term project that is complex to deliver, a time frame is difficult to reliably commit to, the aim will be scoping from January 2019. 8) The Director of Nursing will commission six monthly snap audits to establish compliance with the standard and take necessary steps to improve compliance. Audits commissioned, results to be delivered between August 18 and January 19 and to be considered in the Quality Governance meetings for each Operational Directorate, | trust that these actions address the five concerns that are set out in section 5 of the preventing further deaths report. | am happy to answer further questions or provide further information should that be necessary. Yours sincerely Beverley Murphy Director of Nursing
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