Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0365, written 22 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 | 22 Nov 2018 |
|---|---|
| Reference | 2018-0365 |
| Deceased | Matthew Craven |
| Coroner | Alison Mutch |
| Coroner area | Manchester South |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths · Mental Health related deaths |
| Organisation named | Pennine Care NHS Foundation Trust |
| 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.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS | REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: The Chief Executive of Pennine Care NHS Foundation Trust CORONER | am Alison Mutch, Senior Coroner, for the Coroner area of South Manchester 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 20° April 2018 | commenced an investigation into the death | | of Matthew Gerard Craven. The investigation concluded on 1st | November 2018 and the conclusion was one of Accidental Death. The medical cause of death was 1a) Pregabalin Toxicity 2) Codeine and Chlordiazepoxide use, Pulmonary | Embolism due to Deep Venous Thrombosis Matthew Gerard Craven was prescribed pregabalin for his anxiety. Following his discharge from Stepping Hill Hospital on 17th April 2018, he consumed pregabalin in excess of the prescribed amount. He had done this previously with no ill effect. On 19th April 2018, Matthew Gerard Craven was found dead at his home address, RE | 0Xicology showed that he had a fatal dose of pregabalin in his system. 5 | 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 will occur unless action is taken. In the circumstances, it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. — The inquest heard that: He had long-term anxiety. Mental Health workers assessing him had repeatedly felt he needed to be seen by a psychiatrist. The referrals were rejected by the psychiatrist. There was no challenge or escalation process within the trust to deal with the situation. A routine psychiatric out patient was offered after his mother indicated she would make a formal complaint. The inquest heard that there were no agreed target timescales for the offering of routine appointments. There had been a series of attendances at the emergency department and RAID referrals. The inquest heard that there was no documentation or rationale provided for why RAID did not refer him to a psychiatrist. On one admission to the acute hospital following an overdose, he was seen by an alcohol worker from the Mental Health Trust. There was no evidence that that worker had checked to see or understand any previous engagements with Mental Health Services. Information about that admission and encounter was not shared with wider mental health services even though they were part of the same trust. ACTION SHOULD BE TAKEN In my opinion, action should be taken to prevent future deaths and | 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 17" January 2019. 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. COPIES and PUBLICATION | have sent a copy of my report to ) to the following Interested Persons namely he deceased’s mother, who may find it useful or of interest. | 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. Alison Mutch OBE HM Senior Coroner 22.11.2018 GN
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.
10th January 2019 Strictly Private and Confidential Alison Mutch HM Senior Coroner Coroner's Court 1 Mount Tabor Street Stockport SK1 3AG Dear Ms Mutch Re: Matthew Craven — DOD 19" April 2018 NHS Pennine Care NHS Foundation Trust Service/Department Name Trust Headquarters 225 Old Street Ashton-under-Lyne Lancashire OL6 7SR Telephone: 01614 716 3000 | write following the Inquest of Matthew Craven heard on the 15* November 2018. Your concerns after hearing all the evidence had been brought to my attention and | have subsequently reviewed the Regulation 28 letter. | am writing to respond to the concerns raised into the circumstances surrounding the tragic death of Matthew Craven. The matters of concern raised and the actions we will take to address these concerns are as follows: 1. There is no challenge or escalation process within the Trust to deal with situations where referrals are rejected by the psychiatrist. We will develop a process and protocol for escalation to be used within the borough of Stockport by the end of February 2019. 2. There are no agreed targeted timescales for the offering of routine appointments Following review with the Lead Consultant Psychiatrist the agreed target timescales for routine appointments is 12 weeks. Clear communication of the target timescales will form part of the action above. 3. There had been a series of presentations at the emergency department and RAID referrals. The inquest heard that there was no documentation or rationale provided for why RAID did not refer him to a Psychiatrist. Whilst there were assessments in ED that didn’t result in a referral to a psychiatrist the investigation completed by Pennine Care into the death of Matthew, identified there is evidence on 9th April 2017 that the plan following the RAID team Visit us at www.penninecare.nhs.uk. assessment was to discuss his presentation and medication with the Consultant Psychiatrist and a referral made. On 10 April 2017 the referral for an outpatient appointment was not accepted but the consultant considered the information presented and recommended an increase in medication. Stockport borough will produce an escalation protocol for staff to use when there is disagreement regarding the need for a face to face appointment with a psychiatrist. This will be completed by the end of February 2019. 4. Matthew had one admission to the acute hospital following an overdose and had been seen by an alcohol worker from the Mental Health Trust. There was no evidence that there had been any checking of previous engagements with mental health services. Information about this admission had not been shared with wider mental health services within the same trust. Pennine Care's alcohol liaison practitioners are moving to be based at Stepping Hill Hospital with the all age liaison mental health service and will form part of the same team which will significantly reduce the likelinood of any such concern arising again. The new model will be in place by the end of February 2019. | hope that the information provided offers assurances that the findings of your investigations and the areas highlighted for the prevention of future deaths have prompted action and are a focus of our continuing commitment to improving mental health services in Stockport. Please do not hesitate to contact me should you require any further information. Yours sincerely, Executive Director of Nursing, Healthcare Professionals and Quality 2 10%, o ba z € fe Visit us at www.penninecare.nhs,uk 25a
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