Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0338, written 1 Nov 2018. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 1 Nov 2018 |
|---|---|
| Reference | 2018-0338 |
| Deceased | Billie Lord |
| Coroner | Thomas Osborne |
| Coroner area | Milton Keynes |
| Category | 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.
Regulation 28: REPORT TO PREVENT FUTURE DEATHS (1) NOTE: This from is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: : Matthew Webb, Chief Officer Milton Keynes Clinical Commissioning Group Sherwood Drive Milton Keynes MK3 6RT 1 CORONER I am Thomas R Osborne, HM Senior Coroner for the area of Milton KeyneMilton Keynes 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 On 11/07/2017 I commenced an investigation into the death of Billie Johnathan LORD aged 26. The investigation concluded at the end of the inquest on 26th October 2018. The conclusion of the inquest was a narrative conclusion as follows: Billie Lord died from suicide whilst suffering from psychosis. He suffered from autism and a psychotic illness caused by the use of non-prescription drugs including cannabis. He was referred to the Milton Keynes Crisis team and came under the care of the Acute Home Treatment Team who saw him daily from 5th July 2017. On the 9th July 2017 he was admitted to the Campbell Centre in Milton Keynes as a voluntary patient after being arrested for an assault upon his mother. He was assessed and monitored by intermittent 15 minute observations on Hazel Ward until he absconded at 04.30am on 11th July 2017 by breaking a window with a toilet that he wrenched from the wall. He climbed onto the railway line at Denbigh Hall and ran into the path of a high speed train at 08.40 and died from his resulting injuries. 4 CIRCUMSTANCES OF THE DEATH See Narrative conclusion above. 5 CORONER’S CONCERNS The MATTERS OF CONCERNS are as follows: During the course of the evidence I was informed by an independent expert that it is recognised that patients admitted to an in-patient mental health facility, such as the Campbell Centre, should be cared for in single rooms and that three bedded dormitory accommodation is inappropriate since in this particular case it added to the level of stress suffered by the patient. Consideration should be given to a review of the accommodation provided at the Campbell Centre, and whether alterations can be carried out to bring the accommodation up to modern standards as recommended by the Royal College of Psychiatrists. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) 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 27th December 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 and to the following Interested Persons: The family of Mr Lord Central North West London NHS Foundation Trust 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 Tom OSBORNE Senior Coroner for Milton Keynes Dated: 01 November 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.
NHS Milton Keynes Clinical Commissioning Group 25" January 2019 NHS Milton Keynes Clinical Commissioning Group Sherwood Place Sherwood Drive Bletchley Coroner's Officer MK3 6RT HM Coroner's Office Civic Offices Telephone: 01908 278685 1 Saxon Gate East Email me “ee Mikon Reyncsihiss/3Ed Web: www.miltonkeynesccg.nhs.uk Dear Ms Toms, Regulation 28 Response — Billie Johnathan Lord (BUL) Who Died on 11° July 2017 | am writing in response to your Regulation Report dated 1° November 2018 following the death of Billie Johnathan Lord on 11" July 2017. Thank you for inviting comments from Milton Keynes CCG and please accept our sincere apologies for the delay in responding. Unfortunately, this report was misplaced during a change in personnel. Your Report requests specific feedback relating to the Campbell Centre and its suitability as a Mental Health Inpatient facility. | can confirm that CNWL Mental Health Trust informed the CCG on 3" December 2018 that they are commissioning a study to assess the feasibility of creating a new inpatient campus in Milton Keynes. The outline proposal will bring together acute wards, older adult wards and rehabilitation services. This will allow the Clinical Model associated with all services to be redesigned within a fit for purpose Unit for modern day healthcare delivery. The CCG offers its full support to this significant initiative. The first meeting with planners is scheduled for 28" January. In the meantime, the service always endeavours to keep patients safe by making all reasonable adjustments for those deemed at risk, such as intermittent or continuous observations following a thorough Risk Assessment. Notwithstanding this, even within the current constraints, the informal feedback CNWL received from the Care Quality Commission following an unannounced visit on 16" January 2019 was very positive, particularly with regard to the excellent compassionate care they observed. In addition, MKCCGs Mental Health Commissioner and Quality Team members regularly meet with CNWL to gain assurance regarding all aspects of patient safety and the effectiveness of related services and pathways as weil as to monitor progress against action plans for Serious Incidents and other areas requiring improvement. | trust that this provides you with the appropriate information relating to this case and assurance regarding the development of Mental Health provision in Milton Keynes. Yours sincerely, / Chief Operating Officer Milton Keynes CCG
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