Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0152, written 18 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 | 18 May 2018 |
|---|---|
| Reference | 2018-0152 |
| Deceased | Henry Heselton |
| Coroner | Caroline Topping |
| Coroner area | Surrey |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
IN THE SURREY CORONER’S COURT
IN THE MATTER OF:
__________________________________________________________
The Inquest Touching the Death of
Henry James Heselton
A Regulation 28 Report – Action to Prevent Future Deaths
__________________________________________________________
THIS REPORT IS BEING SENT TO:
Julie Dawes the Chief Executive Officer of Southern Health NHS
Foundation Trust , Tatchbury Mount, Calmore, Southampton, SO40 2RZ
1
CORONER
Caroline Topping HM Assistant Coroner for the County of Surrey
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
An inquest into the death of Mr Henry James Heselton was opened on 7th October 2016
and resumed on 26th January 2018. It was concluded on 4th April 2018. I concluded that
Mr Heslton died on the 28th September 2016 at Down Lane Guildford. and that the
medical cause of his death was:
1a Hanging
Henry Heselton died at Down Lane, Guildford. He had suffered from paranoid
schizophrenia for many years which had been controlled by medication. He had
expressed suicidal ideation for many years. It is not possible to find what triggered the
relapse of his mental health which led him to take his own life nor whether more
proactive mental health support could have prevented his death. He hanged himself on
the 28th September 2016.
Conclusion as to death;
Suicide
4
CIRCUMSTANCES OF THE DEATH
Mr Heselton was born on the 30th January 1985. He obtained 2 degrees and worked as
an audiologist at Royal Surrey Hospital in Guildford. He was a very conscientious young
man. In 2008 he was diagnosed with paranoid schizophrenia. His mental health care
was provided by a community mental health team from Southern Health NHS. He did
not want any treatment to impact on his work. A care plan was put in place which
accommodated his wishes and which relied on his Mother to be his carer. Mrs Heselton
was authorised to liaise with mental health professionals on his behalf. Her contribution
was regarded as an integral part of his care plan. In addition, Mr Heselton’s GP surgery
made arrangement for Mr Heselton to have regular blood tests because of the
1
medication he was taking. This involved him attending the surgery on a monthly basis
and seeing one of the nursing staff. He saw his psychiatrist for annual reviews. He did
not want a care co-ordinator.
rang the
On Sunday the 28th August 2016, on a bank holiday weekend,
East Acute Mental Health Team crisis team run by Southern Heath Trust. Her son was
in crisis. She sought advice about medication. She said that she thought Mr Heselton
might kill himself that day, he could be heard highly distressed in the background. The
crisis team was one member of staff short that day. The mental health nurse practitioner
answering the phone did not have time to read Mr Heselton’s medical records. She
suggested ringing an out of hours GP. No follow up call was made to
the call was not subject to a multi-disciplinary discussion. Details of the call were
forwarded to the community mental health team. They were not at work until the
following Tuesday. Mr Heselton’s general practitioner,
call.
, was not notified of the
and
On Wednesday 1st September 2016 Mr Heselton’s psychiatrist,
, called
. He was informed that Mr Heselton’s mental health had deteriorated but from
the information provided by
significant risk. He made an appointment to see Mr Heselton on the 23rd September
2016 after he had had his blood test at the surgery. This call was not notified to
he did not regard Mr Heselton to be at
said she thought Mr Heselton would not attend the psychiatric
appointment.
On the 7th September 2016 Mrs Heselton called
mental health and ask about medication. From the information she was given
did not think Mr Heselton was actively suicidal. That assessment was made without
to discuss Mr Heselton’s
having been made aware of the 2 recent contacts with
.
was therefore not able to make a fully informed decision about Mr Heselton’s treatment
and was not able to undertake a fully informed risk analysis.
On the 23rd September 2016 Mr Heselton attended at the surgery to have his blood
tested but did not attend his psychiatric appointment. On the 27th September 2016
was unable to contact Mr Heselton. She tried to call the police but did not use
999. She feared he had killed himself. The following day she was notified that Mr
Heselton had not arrived for work. She called the police and Mr Heselton was found in a
field off Down Lane Guildford. He had hanged himself.
had been talking about killing himself for 4 days.
told the police he
An investigation by Southern Health Trust concluded that there had been a missed
opportunity to engage with Mr Heselton and to have a mental health assessment on the
28th August 2016. In addition, that it was essential that staff answering crisis calls
familiarise themselves with the patient’s mental health records.
Professor Fox a Consultant Psychiatrist gave evidence as an expert at the inquest. In
his view the 3 contacts with
mental state. More should have been done to engage and support
and
communication should have been better between the crisis team and the community
mental health team, and with
to engage with mental health services, the decision whether to undertake a mental
health assessment of Mr Heselton was a difficult one and may have undermined his
therapeutic relationships with the mental health professionals.
should have raised alarm about Mr Heselton’s
. He accepted that, given Mr Heselton’s reluctance
5
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 could occur unless action is taken. In the
circumstances it is my statutory duty to report to you.
The MATTERS OF CONCERN are as follows. –
2
1. The electronic mental health records were unclear. Vital information about Mr
Heselton’s mental health history, including that he had attempted suicide in the
past, was difficult to find. His most recent care plan did not record this. The
information was not easy to extract for professionals needing to find information
about a patient in a crisis.
2. There was a lack of communication between the mental health teams and the
general practitioner. The fact that contact had been made by
both the acute and community mental health team was not shared with his
General Practitioner. This left her without relevant recent history to inform her
clinical judgement when she was contacted by
September 2016.
on the 7th
with
6
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe your
organisation has the power to take such action.
7
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report,
namely by July 2nd 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.
8
COPIES and PUBLICATION
I have sent a copy of my report to the following:
1. The Chief Coroner
2.
3.
4.
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.
9
Signed:
Caroline Topping
Dated this May 18th 2018.
3
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.
NHS Southern Health NHS Foundation Trust Trust Headquarters Ref: NB/HR/401262 Tatchbury Mount 7 Sterne Road 21 June 2018 Calmore Southampton $040 2RZ Private and Confidential HM Assistant Coroner Caroline Topping HM Coroner's Court Website: \ywww.southernhealth.nhs.uk Station Approach Woking Surrey, GU22 7AP Dear Ms Topping Regulation 28 Report — Henry Heselton | write further to the above issued on 21 May 2018, following the conclusion of the inquest into the death of Henry Heselton. | note your areas of concern, which | will address in turn, are as follows: 1. The electronic mental health records were unclear. Vital information about Mr Heselton’s mental health history, including that he had attempted suicide in the past, was difficult to find. His most recent care plan did not record this. The information is not easy to extract for professionals needing to find information about a patient in a crisis. It has been recognised, by the Trust, that our electronic patient record, RiO, supports the recording and sharing of vital clinical information, including risk, more effectively than the previous paper record system, including improved legibility, organisation, sharing and identification of key information. However the system has faults and limitations, and information can be difficult to find. It is therefore subject to ongoing review so that it can be redesigned in a way which supports clinical practice. The clinical workforce receives training and support to be able to use the system effectively. The concern that vital information has not being readily available has been accepted and action taken to remedy this. There has been, since January 2017 (evaluated in April 2018), a revised Risk Summary Section in which all staff including medical staff are required to input risk information, according to national guidance (2008). This guidance specifies that there should be clear documentation of risk factors: demographic, background, clinical history, psychological and psychosocial factors and current context. The clinical assessment of these factors leads to a management plan which will include a ‘My Safety & Crisis Plan’ (a collaborative approach to safety planning). This is monitored, and staff are prompted to complete or update the plans at regular intervals, and this should always happen an,” there is a significant change in risk. , There has also been a review of the care planning process, and a Community Care Plan page developed (since January 2018), where all care plans are inserted so that they can be readily identified as well as the Risk summary. —————— OUR VALUES Patients & @ people first PP) Parinerstip | 2. There was a lack of communication between the mental health teams and the general practitioner. The fact that contact had been made by Nirs Heselton with both the acute and community mental health team was not shared with his. General Practitioner. This left. her without relevant recent history to inform her clinical judgement when she was contacted by IY on the 7" September 2016. Safe and effective clinical care is dependent on appropriate information sharing with patient, carer, GP and other agencies and this includes assessment of risk and care planning. At the following times information should be shared with primary care: o After referral to Mental Health Services to let the GP know of the triage process which will include a plan for assessment to occur and the timing of it or other advice or signposting (which did not occur on the occasion referred to) o After each initial assessment with details of the assessment, including risk. o Psychiatric out-patient. appointments o Discharge from inpatient services o Care Programme Approach meetings: these are care planning meetings involving the patient, their family and the important services that.aré involved in the patients care, eg. Housing, social care, community teams, police. o Communication should also occur when fthere.is a request to a GP for support with medication or physical health review. Electronic communication has being developed to allow access to CHIE (formerly the Hampshire Health Record) and GP summary patient records and is being developed to allow access for GPs to the mental health record. But this does not mean that communication described above will be superseded. To address the shortcomings in the care provided to Mr Heselton, these principles have been included in the review of the Acute Mental Health Team and Community Mental Health Team Standard Operating Procedures, and the team: managers instructed to ensure that staff are aware of the requirement to communicate with-GPs after triaging referrals and to regularly monitor that it is occurring. | do hope that this letter provides you with the information: and assurance that you require regarding the measures that have been put in place. Please do not hesitate to contact me if’you require any further information. for —— Dr Nick Broughton FRCPsych Chief Executive Officer Yours sincere,
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