Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0361, written 13 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 | 13 Nov 2018 |
|---|---|
| Reference | 2018-0361 |
| Deceased | Matthew Arkle |
| Coroner | Nigel Parsley |
| Coroner area | Suffolk |
| Category | Mental Health related deaths · Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Norfolk and Suffolk NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
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REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: The Chief Executive, Norfolk and Suffolk NHS Foundation Trust, Trust Headquarters, Hellesdon Hospital, Drayton High road, Norwich’ NR6 5BE. 1 CORONER 1am Nigel Parsley, Senior Coroner, for the coroner area of Suffolk. 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. b | INVESTIGATION and INQUEST On 7 April 2017 | commenced an investigation into the death of Matthew Sean Arkle. The investigation concluded at the end of the inquest on 1st November 2018. The conclusion of the inquest was that; Matthew Arkle died as the result of suicide. Matthew was a voluntary patient at the Wedgewood Unit, West Suffolk Hospital who was granted one hours unescorted leave on the 4" April 2017 but did not return. On the morning of 6 April 2017 Matthew was found hanging next to a tree in an area of heath land directly adjacent to the West Suffolk Hospital in Bury St Edmunds. He was pronounced dead at the scene. The medical cause of death was confirmed as: 1(a) Hanging 1(b) 1(c) 2 Schizophrenia and depression. 4 | CIRCUMSTANCES OF THE DEATH Matthew Arkle was a 37 year-old man with a diagnosis of paranoid schizophrenia. He had been mentally unwell for some time and had a number of admissions to hospital under the Mental Heaith Act (his first in the year 2000). In December 2016 Matthew took an over dose of prescription medication and was admitted as an inpatient until the 1s February 2017. On the 17" February 2017 he was re-admitted to the Wedgewood Unit, West Suffolk Hospital as an informal patient following a further over dose of prescription medication. consideration and risk assessment process by the nurse who authorised the unescorted leave. it was acknowledged that this information may not have changed the decision, but it was deemed to be an important factor to take into consideration. It was further acknowledged, that due to Matthew's generally compliant nature, had he been asked not to take unescorted leave that day (due to his families concerns) then he may well have remained on the ward of his own choice. Witnesses on duty on the Northgate ward on the 4!" April confirmed that they were unaware of Matthew's family request regarding leave that day. Further, there was no written note of the families request on Matthews case file and no witnesses had any memory of it being verbally raised at the ward handover meeting at the start of the shift. It was reported that the activity on ward was extremely high on the 4" April 2017. It was heard that although staffing met the required levels, there were a number of patients requiring additional supervision and a high number of ‘staff personal alarms’ were being activated during the shift. The charge nurse on duty said “I cannot stress enough how busy it was that day” and agreed the ward on the 4" April could be described as being chaotic. In part, this was held fo be the reason that Matthew’s time of leaving Northgate ward to go on unescorted leave was originally recorded to be 19.00 with the police subsequently being alerted to his missing person status at 21.06. CCTV evidence secured from a local garage in the weeks following his death showed that Matthew must have left the ward no later than 17.30 on the evening of the 4'" April. It was subsequently identified that the 19.00 timing had been an ‘approximation’ with it being agreed 17.30 would be a realistic time for Matthew having left the ward. As such Matthew's unescorted leave should have ended at 18.30 with the alarm being raised for Matthew's absence occurring much earlier than it did. This would have allowed searches undertaken by hospital staff, Matthew's family and the police to commence sooner. It was confirmed during the hearing that in relation to patients going missing, there is no policy in place for a review CCTV footage available at the Wedgewood Unit or the West Suffolk Hospital to confirm time of leaving, direction of travel, etc. This would have clearly provided an accurate time and possibly direction of travel in Matthew's case. It was heard that once the Suffolk Constabulary were informed of Matthew's absence they instigated their missing persons protocol designating Matthew as a medium risk on the basis of the information received from staff at the Northgate ward. On the basis of the information the Suffolk Constabulary received this was found to be the appropriate level when reviewing their risk assessment process. However, Suffolk Constabulary were not told that Matthew had seriously attempted suicide on two occasions in the past three months, were not told that his family had specifically requested he not be granted unescorted leave on the 4th April or that on the previous day Matthew's care coordinator had described him “as the lowest | have seen him for some time.” It was heard that there was no set format for the type or nature of the information to be given to the police when a patient goes missing and what information was available in Matthew's case was incomplete (including no recent photograph). in evidence it was heard that had the Suffolk Constabulary been given the above information at the time of his going missing that “in all likelihood” Matthew's risk would have been assessed as being ‘high’. it was then explained that once a ‘high’ risk had been declared additional police resources would have become available. This included the immediate deployment of up to 10 police officers to assist in the initial search for Matthew on the night of the 4h April. In relation to the timing of Matthew's unescorted leave it was well documented in his notes that his auditory hallucinations became strongest in the evenings which was often associated with a lowering in his mood. The charge nurse who granted the unescorted leave said that when they did so they could not see any evidence of ‘internal stimulation’ from auditory hallucination explaining that Matthew did not appear vacant or distracted. However, when coupled to the other identified factors in this case the timing of Matthew's request for unescorted leave was not an identified feature of the risk assessment process prior to his unescorted leave being granted. The jury recorded that the following circumstances may have contributed.to Matthew's death:- 14. A failure of appropriate record keeping within Northgate ward. 2. A failure of verbal and written communication within Northgate ward. 3. The general high level of activity and stress on Northgate ward on the 4th April 2017. 4. The delay in noticing, reacting and reporting Matthew as missing. 5. The timing of Matthews release being late afternoon. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you or 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 8 January 2018. I, the Senior Coroner, may extend the period if | consider it reasonable to do so. 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 I have sent a copy of my report to the Chief Coroner and to the following Interested Person’ s. gama 2" Suffolk Constabulary. lam 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 Senior Coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. 13" November 2018 Nigel Parsley “oe sepnneeeteperappecnreapciaptetipsiiipieesett Hp
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.
Our Ref. ML/AL Norfolk and Suffolk NHS Foundation Trust Trust Management Your Ref. 1 Floor Admin -7 JAN ang Hellesdon Hospital Private and Confidential Drayton High Road Mr Parsley Hellesdon Suffolk Senior Coroner Norwich The Suffolk Coroner's Service ’ NR6 5BE Beacon House ; : oo Whitehouse Road Ipswich : -3 January 2019 © Suffolk : , IP1 5PB Dear Mr Parsley Re: Mr Matthew Arkle | write in response to your report dated 13 November 2018. Under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 you requested the Trust consider issues of service delivery following the conclusion of the inquest into the death of Mr Matthew Arkle. You raise a number of areas of concern which | réspond to in order: Verbal and written communication The inquest heard that Matthew’s family would not be able to visit him at the Wedgwood Unit on 4 April 2017. Three family members had spoken with staff asking that any request for unescorted leave be declined for that day. The inquest heard that the staff on duty on 4 April 2017 were unaware of such a request and there was no written communication to this effect. Communication is a vital component in maintaining safe and effective care. The Trust uses systems such as an electronic patient record to document patient care, as well as frameworks to handover information (Situation, Background, Assessment, Recommendation (SBAR)). However, this tragic event highlights the human aspect of receiving information and ensuring it is fed into these communication structures. There is no current single evidence based tool which can be implemented to eliminate this potential. However, shared understanding amongst staff of the processes of receiving. information ‘is critical to reduce variance. To this end we have issued an internal alert to all our inpatient wards directing reflection on the points where information is received from external sources e.g. families and carers and whether there is a shared process or understanding of how to ensure that information is captured. Where there may not be a shared understanding the ward will work to address this. Feedback from this alert will be shared across the wards to promote wider learning. General high level of activity and stress on Northgate ward on 4 April 2017 The inquest heard that although staffing met the required levels, there were a number of service users requiring additional supervision and a high number of alarms being activated throughout the shift. Se, i Vice Chair: Tim Newcomb Chief Executive: Antek Lejk ay oe Working together Trust Headquarters: Hellesdon Hospital, Drayton High Road, Norwich NR6 5BE for better mental health Tet: 01603 421421 Fax: 01603 421341 www.nsfi.nhs.uk The activity on a ward can vary from day to day having an impact on the experience for service users, visitors and staff. It is important that services can adapt to changing needs. The Trust has been in process of using a validated tool (known as the Hurst tool) to assess the activity of wards. Having completed the required observations the Trust is now receiving the externally validated reports. These will be used to guide future practice. Our intention is that by using a validated tool it will support evidence based decisions supporting safety and quality of care. Delay in noticing, reacting and reporting Matthew as missing. The inquest heard there was a lack of clarity of the time that Matthew went on unescorted leave, with an initial recording of it being at 19.00. CCTV footage enabled a closer estimation of the time being no later than 17.30. Subsequently, Matthew's leave should have ended at 18.30 but it was not until 21.06 that he was reported as a missing person to the police. It is vitally important the Trust employs suitable processes to ensure accurate recording of times when service users are present on or away from the ward. Of equal importance is a shared understanding of the time when a person goes on leave and that there is prompt alarm and action should they not return at the agreed time. ‘ The Trust has issued an internal alert highlighting the need for clear processes to support this, and learning from areas with. strong actions will be shared and adopted amongst the Trust. Trust policy Missing Persons and Failure to return from Leave supports staff actions when a person does not return from leave. This guides the process of actions and completion of information with a specific form that is provided to the Police. This policy was created with Norfolk and Suffolk Police and published in May 2017. Timing of Matthew’s release on leave being in the late afternoon. The inquest heard that it was well documented that Matthew's symptoms of auditory hallucinations became strongest in the evening, often associated with a lowering in his mood. The Trust’s Root Cause Analysis réport examined the timing of Matthew's leave and whether the practitioner in charge was aware of his symptoms and how hallucinations could become stronger in the evening, influencing his mood. The report identified the practitioner was aware of Matthew's presentation and the balance of what distraction could offer. The report identified the assessment was satisfactory with Matthew presenting positively in language and manner. — Understanding and research of suicide does not yet provide us with a structure by which to predict people taking their lives, with tools giving broad indicators of higher risk. This means assessment relies partly on judgement. Regrettably, we will not know the mental torment Matthew experienced preventing him from speaking about any thoughts of suicide with the staff at that time. Equally, we will not know whether these thoughts became more dominant or surfaced once he went on leave. If | can be of any further assistance please do not hesitate to contact me. Yours sincerely Antek Lejk Chief Executive 28, | Vice Chair: Tim Newcomb Chief Executive: Antek Lejk Bee Working together Trust Headquarters: Hellesdon Hospital, Drayton High Road, Norwich NR6 SBE “= for better mental health Tel: 01603 421421 Fax: 01603 421341 www.nsft.nhs.uk
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