Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0282, written 14 Sep 2018. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 14 Sep 2018 |
|---|---|
| Reference | 2018-0282 |
| Deceased | Terence Bennett |
| Coroner | Nicholas Rheinberg |
| Coroner area | Wiltshire and Swindon |
| Category | Mental Health related deaths · Suicide (from 2015) |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
HM Assistant Coroner
for Wiltshire and Swindon
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
Chief Executive
Avon and Wiltshire Mental Health Partnership NHS Trust
Bath NHS House
Newbridge Hill
Bath BA1 3QE
and for information purposes to:
NHS Improvement
NHS England
Care Quality Commission
1
CORONER
I am Nicholas Leslie Rheinberg an Assistant Coroner for Wiltshire and Swindon
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.
http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7
http://www.legislation.gov.uk/uksi/2013/1629/part/7/made
3
INVESTIGATION and INQUEST
On 27th October 2016 an investigation was commenced into the death of Terence Andrew
Bennett aged 45. On the 14th September 2014 the inquest was concluded. I sat with a jury. The
jury found that the medical cause of death was
1a) Incised wounds to neck 2 Coronary Artery Disease.
4
5
The jury concluded that the deceased died by suicide; his death was contributed to by neglect
CIRCUMSTANCES OF THE DEATH
The deceased suffered from schizo-affective disorder and had done so for more than 20 years.
In acute phases of his illness he posed as a high risk to both himself and others. In August 2016
he began to relapse and by 25th October 2016 he was severely mentally ill, suicidal and
threatening physical harm to his Mother. During the evening of 26th October 2016, he self-
inflicted 19 deep lacerating wounds to his neck, partly severing the jugular vein and a great
number of incised wounds to his left and right wrists. He physically resisted attempts to save him
and following collapse was pronounced dead at 32 minutes past midnight on 27th October 2016
CORONER’S CONCERNS
During the course of the inquest it emerged that there were gross failures in respect of the care
provided to the deceased by your trust to the extent that the jury found that the deceased’s death
had been contributed to by neglect.
My specific concerns are as follows:
1.
sufficient information.
2.
computerised medical records, in respect of a generic system which itself did not sufficiently
cater for the particular requirements of Avon and Wiltshire Mental Health Partnership NHS Trust.
Care, Risk and Crisis Management plans were not robust enough and failed to contain
Staff had insufficient knowledge of how to access, interrogate and effectively use
Wiltshire & Swindon Coroner's Office, 26 Endless Street, Salisbury, Wiltshire, SP1 1DP
Tel 01722 438900 | Fax 01722 332223
There appeared to be deficiencies in the supervision of unqualified mental health
Unqualified staff were relied upon in circumstances where qualified staff should have
There was a lack of involvement of family members and in particular, the concept of a
There did not appear to be a system of peer review within the mental health teams nor a
3.
triangle of care which involved family, the patient and the medical team had largely been
ignored.
4.
system of external audit as regards the adequacy of care plans and medical records.
5.
been assigned.
6.
workers.
7.
complex mental health needs.
8.
appeared to be a lack of a proper handover between the healthcare professionals.
9.
allocation of time, the acquisition and deployment of necessary skills and the establishment of
satisfactory ways of working.
10.
faced a full day of clinical work immediately following the completion of a 12 hour night time duty,
without any period of rest and recuperation.
The on-call rota for duty consultants meant that consultant psychiatrists on occasions
Much of the above implied serious gaps in the adequacy of training / knowledge, the
There was little evidence of multi-disciplinary working in relation to an individual with
When there was a change in personnel responsible for the care of the patient, there
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
10th November 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 Chief Coroner, NHS Improvement, NHS England and to
the family of the deceased.
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 assistant coroner, at the time of your response, about
the release or the publication of your response by the Chief Coroner.
9
Dated 14th September 2018
Signature_________________________
Nicholas Leslie Rheinberg
Assistant Coroner for Wiltshire & Swindon
Wiltshire & Swindon Coroner's Office, 26 Endless Street, Salisbury, Wiltshire, SP1 1DP
Tel 01722 438900 | Fax 01722 332223
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.
INHS| Improvement Medical Directorate Nicholas Leslie Rheinberg NHS Improvement Assistant Coroner for Wiltshire and Swindon Wellington House Wiltshire & Swindon Coroner's Court 133 - 135 Waterloo Road 26 Endless Street London SE1 8UG Salisbu Wiseie T: 020 3747 0000 E: nhsi.enquiries@nhs.net SP11DP W: improvement.nhs.uk 19 November 2018 Dear Mr Rheinberg RE: Terence Andrew Bennett deceased | am writing in response to your letter dated 14 September and the attached copy of the report following the Inquest into the death of Mr Bennett. Please accept my apologies for our delay in responding. On behalf of NHS Improvement (NHSI) may | take this opportunity to express our sincere condolences to the family of Mr Bennett following his tragic death. NHSI is grateful to you for sharing the report and, as you suggest, acknowledge the findings have relevance to other Trusts in the country. We will ensure they are shared internally. The Coroner may also find it helpful to know about a national programme to improve mental health services and how we are working with the Trust to address the failings identified in the Coroner's report. | have set out details below. This year NHSI in partnership with the Care Quality Commission (CQC) was tasked by the Secretary of State to improve patient safety in mental health trusts by delivering a national mental health safety initiative. The overall aim of the programme is for every NHS trust providing core mental health services in England to have understood their safety priorities and have made a measurable improvement in at least one key area of mental health safety by 31 March 2020. In order to meet this aim, the programme will work to: e Align Arm’s Length Bodies (ALBs) understanding and resources relating to safety, assurance and improvement culture e Create sustainable mental health improvement resources e Map existing networks, resources, and best practices relating to safety across mental health services e Work with the Department of Health and Social Care to ensure its approach is aligned to national policy NHS Improvement is the operational name for the organisation that brings together Monitor, NHS Trust Development Authority, Patient Safety, the National Reporting and Learning System, the Advancing Change team and the Intensive Support Teams. The programme’s underlying approach to safety is one that addresses leadership, capability and culture. The key areas of focus are: e Safety on mental health wards (including restrictive practice, violence and sexual safety) e Medications management e Use of informatics to support safety at all levels e Environmental awareness e Safe management of referrals and waiting lists e Increase in knowledge and expertise at a regional level e Plus, any key areas agreed by individual trusts and the Mental Health Safety Improvement Programme. In addition, the Five Year Forward View for Mental Health set out clear recommendations on suicide prevention and reduction, and made a commitment to reduce suicides by 10% nationally by 2020/21. Alongside this, the Secretary of State announced a zero suicide ambition for mental health inpatients in January of this year and NHSI is working closely with other ALBs to help services achieve this aim. The approach includes supporting trusts to develop a clear understanding of the definition and practical implementation of the ambition including processes to support the identification of patients who present as a high risk of self-harm or suicide. In addition to these points relating to improving patient safety in mental health, | outline below our regulatory and oversight approach with system partners to provide assurance that appropriate action is taken to address the serious failures identified through this, and other Coroner's reports. As you may be aware, the original incident was recorded as a Serious Incident (SI) on the Strategic Executive Information System (known as StEIS) in accordance with the Serious Incident Framework. Under the Framework, a trust's CCG (in this case Wiltshire CCG) oversees its response to an SI, both the immediate action required through to undertaking the investigation and producing a final report and action plan. If there is a Coroner’s inquest the SI is not closed until the outcome from the inquest is known and a satisfactory response/action plan is developed. When the Regulation 28 letter was received by Wiltshire CCG in September 2018 it did raise concerns similar to the themes previously identified by the Trust’s ‘root cause analysis’ (that was undertaken as part of the investigation into the SI) particularly around reducing the number of suicides. These concerns led to the system partners setting up a quality improvement summit to focus on suicide prevention, with its first meeting being held in September. The follow up is planned for December 2018. NHSI, NHS England, Wiltshire CCG, Swindon CCG and Bristol CCG are participating in this. NHS Improvement is the operational name for the organisation that brings together Monitor, NHS Trust Development Authority, Patient Safety, the National Reporting and Learning System, the Advancing Change team and the Intensive Support Teams. In addition, the system partners have been working together to review the co-ordinated regulatory/oversight approach to the concerns and failings identified by the Coroner. NHSI has discussed with the Trust the Coroner’s report and the key changes that have already been put in place. It has also commented on the Trust's response to the Coroner and action plan to address the issues raised. We will continue to oversee and hold the Trust to account for its actions at our monthly oversight meetings and through regular calls with the Trust’s Director of Nursing and Medical Director. NHSI is also working with the Trust and key partners on a support package for the Trust as it reviews and strengthens its governance arrangements for quality. | trust you will find this information of assistance and should you require any further detail please do not hesitate to contact me. Yours sincerely fe (uth, Ma Dr Kathy McLean OBE Executive Medical Director and Chief Operating Officer NHS Improvement NHS Improvement is the operational name for the organisation that brings together Monitor, NHS Trust Development Authority, Patient Safety, the National Reporting and Learning System, the Advancing Change team and the Intensive Support Teams.
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