Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0189, written 21 Jun 2018. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 21 Jun 2018 |
|---|---|
| Reference | 2018-0189 |
| Deceased | John Hazlewood |
| Coroner | Lydia Brown |
| Coroner area | Leicester City and South Leicestershire |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Leicestershire Partnership NHS Trust · University Hospitals of Leicester NHS Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. 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: Dr P. Miller, Chief Executive, Leicestershire Partnership NHS Trust. Mr J. Adler, Chief Executive, University Hospitals Leicester NHS Trust. 1 CORONER am Lydia Brown Assistant Coroner, for the area of Leicester City and Leicestershire South 2 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. 3 INVESTIGATION and INQUEST On 3`d February 2017 I commenced an investigation into the death of John Charles Hazlewood. The Inquest concluded on 13 June 2018. Cause of death: Inhalation of white spirit and injury of the right ulnar artery. 4 CIRCUMSTANCES OF THE DEATH John died 31 January 2017 at , Wigston, Leicestershire. Narrative conclusion. John presented to mental health services during January 2017 with increased anxiety and initially was appropriately assessed by his community psychiatric Consultant and then by a MHP in the urgent care centre at Leicester emergency department. Despite denying any intention of self-harm, 2 days later he was admitted via the emergency department to the Leicester Royal Infirmary after a mixed overdose of alcohol and cardiac medications. John self-discharged later the same day. No mental health assessment was carried out and this was a missed opportunity to re-evaluate his ongoing care in the light of the material changes in his presentation. No notes were made in the psychiatric record and this caused community safety netting to fail. John barricaded himself into his garage, significantly self-harmed using hand tools available to him and consumed a large amount of white spirit. He died, notwithstanding emergency assistance, as a result of his actions. He intended to take his own life and understood the consequences of his actions. 5 CORONER'S CONCERNS 1. The court heard that the on call Dr for psychiatry did not have remote access to Mr Hazlewood's medical records and this prevented her from being informed of his significant psychiatric history, and furthermore prevented her from writing a note of her discussions regarding his request to self-discharge. Therefore the knowledge that he had presented again via ED with a serious overdose was not available to his Consultant so an opportunity was missed to escalate his care. Many of the on call team do have remote access and the Leicester Partnership Trust are asked to consider this issue for ali relevant clinicians in order to avoid future difficulties of communication. 2. Mr Hazlewood's partner was repeatedly expressed to be his main or only protective factor from self-harm. She was not approached for information regarding his overdose, or her concerns regarding his escalating behavior and this missed an opportunity for the fuller picture to be captured when considering care planning and mental health assessment. This is an issue that I have raised with the Leicester Partnership Trust before in the matter of and it appears that carers/families are still not being routinely involved in the care of mentally unwell patients. This can create intolerable pressures upon families and leads to poor outcomes such as in these 2 cases. LPT are urged to consider how this matter can be embedded in training and practice. 3. The court was assured that the induction process had been changed to improve knowledge regarding on call procedures and availability of medical record access. No information was available, via audit, of whether this amended process is successful. LPT should ensure that the outcomes of their welcome changes are being effectively monitored to ensure clinicians have appropriate training and understanding given the frequent rotations of staff and the importance of the on call system being robust and reliable. 4. University Hospitals of Leicester staff, both Dr and nurse gave evidence to the Court that they had not received any training in self harm, notwithstanding they were both highly likely to encounter patients attending with self-inflicted injuries regularly in both the Emergency Department and in the Acute Medical . Admissions unit. With self-harm statistics sadly soaring, this is an increasing matter of concern. It is not appropriate to rely on "buying in" psychiatric services and leaving front line staff treating patients with no basic knowledge of this complex area and potential triggers, Training would empower the staff and is likely to assist them both in caring for the patients but also the carers/families who may need advice and support. NICE guidelines CG16 is clear that training should be provided to all staff who may encounter such patients and UHL should therefore reconsider this matter. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you have 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 16t" August 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 have sent a copy of my report to the Chief Coroner and to the following Interested Persons: (Sister) (Partner) Leigh Day (Family's Solicitors) (MDDUS) Sir David Behan, Chief Executive, Care Quality Commission. Mr R. Henderson, Chief Executive, East Midlands Ambulance Service , Chief Investigator, Healthcare Safety Investigation Branch. 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 Date: 21St June 2018 Signed by Coro er• `/
2 responses 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.
Leicestershire re ~~c—J Partnership N HS Trust Corporate Affairs Room 170, Penn Lloyd building County Hall Leicester LE3 8TH Tel: 0116 295 1350 Fax: 0116 225 5233 www.leicspart.nhs.uk Direct dial: Email: Our ref: JH —June 18 13 August 2018 By email to Leicester.coroner(c~leicester.gov.uk Lydia Brown Assistant Coroner Leicester City and South Leicestershire The Town Hall Town Hall Square Leicester LE1 9BG Re: John Hazlewood Further to your report dated 21 June 2018, in accordance with paragraph 7, Schedule 5 of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013, I offer the following response. We have investigated the matters of concern that have arisen during the course of the inquest of John Hazlewood. Leicestershire Partnership NHS Trust takes these matters very seriously and I hope that you and Mr Hazlewood's family will be satisfied that we have taken the appropriate measures to prevent such an occurrence happening again. The matters of concern you have raised are as follows: 1. The court heard that the on call Dr for psychiatry did not have remote access to Mr Hazlewood's medical records and this prevented her from being informed of his significant psychiatric history, and furthermore prevented her from writing a note of her discussions regarding his request to self-discharge. Therefore the knowledge that he had presented again via ED with a serious overdose was not available to his Consultant so an opportunity was missed to escalate his care. Many of the on call team do have remote access and the Leicester Partnership Trust are asked to consider this issue for all relevant clinicians in order to avoid future difficulties of communication. Response , Clinical Director, has confirmed that all trainees on the relevant rota in Adult Mental Health and Learning Disabilities service now have remote access to the same clinical systems they would be able to access if they were working on the Trust's sites. This me Chair: Cathy Ellis Chief Executive: Dr Peter Miller Leicestershire Partnership NHS Trust is a smoke-free Trust. Please visit www.leicspart.nhs.uk/smokefree for details mm disability O~ confident EMPLOYER psychiatry junior doctors and specialist trainees who cover the University Hospitals of Leicester NHS Trust out of hours have this access. In addition they also have access to the specific electronic patient record systems, regardless of their speciality, i.e. doctors working in adult services have access to the system used for child and adolescent mental health services and vice versa. 2. Mr Hazlewood's partner was repeatedly expressed to be his main or only protective factor from self-harm. She was not approached for information regarding his overdose, or her concerns regarding his escalating behaviour and this missed an opportunity for the fuller picture to be captured when considering care planning and mental health assessment. This is an issue that I have raised with the Leicester Partnership Trust before in the matter of William Abel and it appears that carers/families are still not being routinely involved in the care of mentally unwell patients. This can create intolerable pressures upon families and leads to poor outcomes such as in these 2 cases. LPT are urged to consider how this matter can be embedded in training and practice. Response Staff in our Assessment and Triage Team endeavor to elicit carers' and families' views regarding the care and treatment of patients, this enables us to gain an understanding of the whole person. However, this is clearly not always as effective as we would like. Although we implemented a number of actions in 2015 in response to the death of Mr. Abel, it is clear we need to continue to reinforce the importance of effective communication with families/carers. With this in mind, our senior Matron will complete work with the teams to ensure all staff in our Mental Health Triage team have a supervision session with the focus on family and carer involvement in the assessment process and discuss ways in which they can improve this within their working practice. This will be completed by October 2018. We have also provided all staff within the Mental Health Triage and Crisis teams with a copy of the NICE guidelines which covers the benefits of family/carer involvement and all staff, receive a Whole Family Approach Bulletin every two months which highlights and shares good practice and learning. We have also commenced a review of the current record keeping audits to expand the family/carer section of the audit. Our compliance will continue to be monitored through our weekly record keeping audits and form part of our monthly clinical governance agenda. 3. The court was assured that the induction process had been changed to improve knowledge regarding on call procedures and availability of medical record access. No information was available, via audit, of whether this amended process is successful. LPT should ensure that the outcomes of their welcome changes are being effectively monitored to ensure clinicians have appropriate training and understanding given the frequent rotations of staff and the importance of the on call system being robust and reliable. Chair: Cathy Ellis Chief Executive: Dr Peter Miller Leicestershire Partnership NHS Trust is a smoke-free Trust. Please visit www.leicspart.nhs.uk/smokefree for details mm disability D~ confident EMPLOYER Response Following Mr Hazlewood's inquest, in addition to the actions taken in response to the serious incident investigation findings, further improvements have been made to the central duty rota (CDR) induction processes. The doctors on the central duty rota cover the LRI out of hours. An induction for the central duty rota doctors was held on 3.08.18 that involved consultants and clinicians from different services that contribute to the CDR on call rota (Crisis team, mental health triage team, liaison team and child and adolescent mental health team). The induction presentations will be video recorded to enable ongoing access for future new starters. In addition this session included a site induction at the LRI for the current CDR on call doctors. The induction provided a comprehensive programme, and will be delivered at every rotation when new doctors join. The central duty rota on call guide has been updated in July 2018 after collaboration with other consultants and the current cohort CDR on call doctors to ensure that it meets their needs. , Consultant Psychiatrist &Associate Medical Director (Postgraduate Medical Education) did an evaluation of the induction feedback, 12 out of 12 trainees participated in the feedback. All 12 rated the induction as good or very good in content, 11/12 rated the quality as good or very good. We hope this reassures you that we have taken appropriate action in response to your findings regarding doctors' access to medical records .systems, involvement of patients' families and on call procedures to provide safe and effective care in order to reduce the risk to our future patients. Yours sincerely Dr Peter Miller Chief Executive Chair: Cathy Ellis Chief Executive: Dr Peter Miller Leicestershire Partnership NHS Trust is a smoke-free Trust. Please visit www.leicspart.nhs.uk/smokefree for details mm disability D~ confident EMPLOYER
,~-~ ~ r7 , QTY U niversity Hospitals of Leicester RlHS Trus# Our Ref: Your ref: 7 August 2018 CEM/GA/00350-2017 Mrs LC Brown H M Assistant Deputy Coroner Leicester City and South Leicestershire Leicester Town Hall Square Leicester LE1 96G Dear Mrs Brown Re John Charles HAZLEWOOD Leicester Royal Infirmary Chief Executive's Corridor Level 3, Balmoral Building Infirmary Square Leicester LE1 5WW Tel: 0116 258 8940 Thank yoga for' your letter dated 215 Junz 2018 in connection with the above matier. I am now in a position to respond. I note that the court made no criticism of the care that we delivered to Mr Hazlewood and I am also pleased to note that the clinical team caring for Mr Hazlewood appropriately contacted Leicester Partnership Trust (LPT) for expert advice on how to best manage Mr Hazlewood's condition. You asked me to address the issue about the training that we provide to staff on mental illness and I am of course happy to do so. Firstly it is important to say that the Trust recognises that the management and treatment of mental illness is a priority for all healthcare bodies including this Trust. To that end we have established a Mental Health Board which is chaired by , our Deputy Chief Operating Officer. Representatives from LPT, the CCGs, EMAS the police and a Patient Partner attend meetings along with subject matter experts and representatives from our Clinical Management Groups. Our Clinical Lead for Mental Health is , Consultant in Emergency Medicine. The Trust, through the Mental Health Board, has drafted a three year mental health strategy, led by , which is expected to be finalised by October 2018 Whilst mental health is not part of our core business we fully accept that we must ensure that our staff are appropriately trained to enable them to deliver appropriate pare to r~atients with mental illness. Nevertheless it will be remain important for UHL staff to seek appropriate advice from LPT staff in the management of patients with mental illnesses as their staff are the recognised experts in this area and a failure to do this this would be expected to result in significant patient harm. ConYd ..... University Hospitals of Leicester NHS Trust includes Glenfield Hospital, Leicester General Hospital and Leicester Royal Infirmary. Website: www.leicestershospitals.nhs.uk Chairman: Mr Karamjit Singh CBE Chief Executive: Mr John Adler -2- Currently we deliver training in self-harm by a number of methods. For staff in our ED, EDU and AMU training is provided to doctors and nurses as part of their orientation/induction programme. Additionally we deliver a Mental Health Study Day which is provided for all nursing staff in ED/EDU and open to other staff. Further training is provided to our medical staff on mental health as part of teaching programmes eg local registrar training and international doctors teaching. We also deliver mental health training through the EM3 website which is operated by the ED education team. To further support staff in this area we have atrust-wide Policy and Procedure for detaining patients under the Mental Health Act 1983. It covers the sections of the Mental Health Act that are most commonly used within a general hospital setting including Sections 2 and 5. This policy has been developed in line with the CQC's Guidance for general hospitals, the Department of Health's 2015 guidance and the Mental Health Act 1983 Revised Code of Practice. This policy is led by our Safeguarding Team and the Board Director Lead for this policy is our Acting Chief Nurse. As you would expect we keep our safeguarding training under regular review and our Head of Safeguarding, , will be presenting a paper to the Safeguarding Assurance Committee on the 15th August 2018 which will recommend strengthening and making more robust our training for all staff who care for people who self-harm. As we will need to involve an external organisation in the development of this training it is anticipated that this will take approximately 6 months to put in place. in the meantime, and as a result of this inquest, our Head of Safeguarding is to ensure that all UHL staff receive a communication to remind them of the escalation process that they can use if they have any concerns about a patient who they feel is at risk of self-harm. We are working with LPT on this communication and we expect this to be sent out before the 15th August 2018. I trust that this letter provides you with the assurance that we are taking this matter seriously. If you would like any further information then please do not hesitate to contact me. Yours sincerely `-- John Adler Chief Executive University Hospitals of Leicester NHS Trust includes Glenfield Hospital, Leicester General Hospital and Leicester Royal Infirmary. Website: www.leicestershospitals.nhs.uk Chairman: Mr Karamjit Singh CBE Chief Executive: Mr John Adler
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