Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0211, written 27 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 | 27 Jun 2018 |
|---|---|
| Reference | 2018-0211 |
| Deceased | Dudley Brown |
| Coroner | Sarah Bourke |
| Coroner area | Inner North London |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| 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.
Coroner ME Hassell
HM Senior Coroner
Inner North London
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
1,
Director of Adult Services
London Borough of Hackney
Hackney Town Hall
Mare Street
London E8 1EA
Dr Kevin Cleary |
Medical Director
East London NHS Foundation Trust
Trust Headquarters
9 Alle Street
London E1 8DE
CORONER
1am Sarah Bourke, assistant coroner, for the coroner area of Inner North London.
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 17 January 2018, | commenced an investigation into the death of Dudley Vincent
Brown (age 58). The investigation concluded at the end of the inquest on 15 May 2018.
The conclusion of the inquest was a narrative conclusion which is set out in the
circumstances of the death below. The medical cause of death was:
1a: multi organ failure
1b: septic shock secondary to Klebsiella bacteraemia
1c: community acquired pneumonia
2: chronic kidney disease, Wernicke-Korsakoff syndrome.
CIRCUMSTANCES OF THE DEATH
Mr Brown had a number of health conditions including nephrotic syndrome, epilepsy,
Wernike-Korsakov Syndrome and recurrent pulmonary embolism. He was in receipt of
a care package to support him with personal care, meals and medication. Mr Brown’s
care package was withdrawn on 27 December 2017 after he threatened his carers with
a metal bar. His Social Worker visited on 29 December 2017 and Mr Brown threatened
her with a knife. The incident on 29 December 2017 was reported to police, who took
no action. Mr Brown's social worker contacted his GP on 2 January 2018 and the GP
referred Mr Brown for an urgent mental health assessment that evening. Mr Brown’s
case was passed to the Approved Mental Health Practitioner Service (AMHPS) on the
morning of 3 January 2018. A warrant was applied for under Section 135 of the Mental
Health Act. This was granted on 8 January 2018. AMPHS also collated information for a
Police risk assessment form, which was completed on 8 January 2018. The form was
referred to the Police Mental Health Liaison Officer along with the warrant later that
day. An appointment was made for the assessment to take place at Mr Brown’s home
at 3 pm on 10 January 2018. When Police and the AMHPS attended the property, Mr
Brown was found on the floor in a state of reduced consciousness. It is unclear how
long he had been there. Paramedics were called and Mr Brown was taken to the Royal
London Hospital where he was found to have multi-organ failure. Mr Brown did not
respond to treatment and died at the hospital on the evening of 11 January 2018.
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. —
{1) Following the incident on 29 December 2017, the incident was reported to police
the same day. The social work team leader dealing with the case was of the view that
the police were the best placed to initiate emergency procedures under the Mental
Health Act.
(2) Mr Brown's care package was withdrawn on 27 December 2017. No arrangements
were put into place for Mr Brown’s welfare to be checked in the period pending a
mental health assessment.
(3) The social work team leader dealing with this case was under the impression that
referrals to the Approved Mental Health Practitioner Service (AMPHS) had to be made
by a GP.
(4) Mr Brown’s referral to the AMHPS and subsequent assessment was delayed due to
intervening weekends (including a 3 day bank holiday weekend).
(5) Mr Brown’s assessment by the AMHPS team was delayed due to the need for.
information regarding the nature of his property being required by the Metropolitan
Police as part of their risk assessment.
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and | believe you and
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,
namely by 23 August 2018. |, 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
| have sent a copy of my report to the Chief Coroner and to the following Interested
Persons.
° a is: of the deceased)
1am 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.
Sarah Bourke
Assistant Coroner 27 June 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.
Hackney Council
Hackney Service Centre
1 Hillman Street
London
E8 1 DY
23rd August 2018
Ms Sarah Bourke
Assistant Coroner
Inner North London Area
Dear Ms Bourke,
RE: Regulation 28 Report to Prevent Future Deaths
Mr Dudley Vincent Brown – DOB: 31/5/59 – DOD: 10/1/18
Address:
Thank you for your Regulation 28 Report issued on 27th June 2008 seeking assurance from the council
and East London Foundation Trust that the circumstances surrounding the death of Mr Brown are
acknowledged and addressed in order to prevent future deaths.
This is a joint response between the Council and East London Foundation Trust. We acknowledge and
accept your recommendations in this case, and have worked together to address the concerns, by way
of formulating and implementing a multi-agency action plan which is attached for your reference.
This focuses upon the following:
Ensuring that all staff, including managers are fluent with the processes for requesting either a
general mental health assessment or a Mental Health Act assessment, which to some degree
have differing referral routes, outcomes and expected response times.
A review of the current escalation pathway for service refusals by either the individual themselves
or other parties on their behalf where a needs-based care package has been commissioned.
A review of the current AMHP referral risk assessment process, including the timely gathering of
necessary information to assist in progressing cases, i.e. property details for Police, etc.
It is expected that this work as a whole, will be completed by the 30th September 2018, with some aspects
having already been completed following the initial inquest.
As an additional assurance, the council and East London Foundation Trust have shared the
circumstances and action plan with the City & Hackney Safeguarding Adults Board via its Safeguarding
Adults Review Sub-Group in order to clarify if the circumstances meet the criteria for a Safeguarding
Adults Review, and, if not, then to ensure that the identified learning points are shared across the
partnership.
We are in agreement to the publication of this response in order to broaden learning, and we will be
liaising with Mr Brown’s sister.
Please do not hesitate to contact me if further clarification is required.
Yours sincerely,
- East London Foundation Trust
See every Prevention of Future Deaths report matching Hospital Death (Clinical Procedures and medical management) related deaths, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.