Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0397, written 19 Dec 2018. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 19 Dec 2018 |
|---|---|
| Reference | 2018-0397 |
| Deceased | Henry Curtis-Williams |
| Coroner | Sean Cummings |
| Coroner area | West London |
| Category | 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 |
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 NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Chief Executive Norfolk and Suffolk NHS Foundation Trust i CORONER | am Dr Séan Cummings Assistant Coroner for the Coroner Area of London (Western Area) 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 the 5'* July 2016 an Inquest was opened into the death of Henry Curtis-Williams. The investigation concluded at the end of the inquest on the 7'* November 2018.The conclusion of the inquest was (2) Hanging (4) Suicide 4 | CIRCUMSTANCES OF THE DEATH Henry Curtis-Williams died from hanging at Acton Cemetery on the 17" May 2018. He had been admitted to the Woodlands Unit on the 11"* May 2016 under police section 136 after he was found contemplating jumping off the Orwell Bridge in Ipswich. He was transferred to nearby Southgate Ward after a mental health assessment. He was discharged the next day without a Consultant review. He travelled to London where he was attending University and was seen and comprehensively assessed by his GP. He died sometime later. 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 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) That following admission to Southgate Ward Henry Curtis-Williams was seen by a number of different staff members. It became evident that there was a Culture of not recording contemporaneous notes. This was very obvious with reference to recording presence or absence of suicidal ideation. There was an acceptance that patients could be discharged by very junior doctors without prior reference to Consultant or Senior colleagues even though Henry had been admitted after being assessed by 2 Section 12 approved doctors and an Approved Mental Health Professional who felt he needed a prolonged inpatient stay. (3) Communication between staff members was very informal with no record S kept of important messages relayed. For example, the member of staff who held a one to one meeting with Henry was not present at the ward round where Henry’s case was discussed but said she had verbally passed a message to the ward round nurse. This was normal practice on this ward. There was no record of the message, or of it being passed or that it was considered at the ward round. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you the Chief Executive of Norfolk and Suffolk NHS Foundation Trust 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 12" February 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 the Chief Coroner and to the following Interested Persons (1) Henry’s mother and father, lam 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 fne, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. 19" December 2018 Dr Séan cu iming§ Assistant Coroner
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) Norfolk and Suffolk NHS Foundation Trust Our Ref. ML/AL LBHF CORONERS & MORTUARY Trust Management Your Ref. : 18 Floor Admin Hellesdon Hospital Private and Confidential i FEB 2019 Drayton High Road Dr Séan Cummings Hellesdon Assistant Coroner . Norwich Area of London (Western Area) s NR6 5BE 25 Bagleys Lane Fulham 7 ; SW6 20QA ; 8 February 2019 Dear Mr Cummings Re: Mr Henry Curtis-Williams I write in response to your report dated 19 December 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 Henry Curtis-Williams. You raise a number of areas of concern which | respond to in order: Recording of contemporaneous notes You identified concern that there was a culture of not recording contemporaneous notes, most obviously related to the recording of the presence or absence of suicidal ideation. | agree it is critical that the service user’s health record demonstrates the care provided in meeting their individual need. In Henry’s case, he had been admitted following a period of experiencing suicidal thoughts, with it reasonable to expect these symptoms were checked during interactions, then to be followed up with the details of discussion recorded in the health record. The Trust's Health record policy provides guidance that entries should be made into the health record as soon as possible from the time of the event. The policy further outlines the requirement of clinical judgement to determine what information to record. To support staff, the Trust will be using Henry’s case in the provision of learning via our patient safety newsletter and- through the range of practice * education teams and staff receive. Linked to this, under the leadership of the Medical Director, the Trust is commencing a programme of work to examine the barriers to using ‘clinical curiosity’ and develop the skills and frameworks for staff to ensure this critical aspect of care is consistently applied. Discharge You identified concern that Henry was discharged by a junior doctor without prior reference to a Consultant or senior colleague. Discharge from hospital can represent a period of uncertainty and risk for the service user. Therefore, it is right to observe that such decisions must be made using members of the multi-disciplinary team who have the required knowledge and skills to support a safe and supportive discharge. Following receipt of your report the Trust has completed an audit to examine the current practice applied. Reviewing eighty-two records, from discharges completed in August and September 2018, the audit confirmed 96% had evidence within the health record that a senior doctor or Consultant had been part of the decision of discharge. To strengthen this, the Medical Director has 2G, WA ‘ Chair: Marie Gabriel CBE, Chief Executive: Antek Lejk See Working together Trust Headquarters: Hellesdon Hospital, Drayton High Road, Norwich NR6 5BE X= for better Mental health Tet 01603 421421 Fax: 01603 421341 www nsft.nhs.uk -ded learning to Consultant Psychiatrists and teaching will be provided to junior doctors as part of their induction to the Trust. Communication between staff You observed that communication between staff was very informal with no record of important messages relayed. You referenced that information did not reach the ward round. 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, and 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. Following some recent learning, the Trust had issued an internal alert to all our inpatient wards directing reflection on the points where information is received from differing sources eg service users, 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 is being received currently which will then be shared across the wards to promote wider learning. If | can be of any further assistance please do not hesitate to contact me. Yours sincerely a Antek Lejk Chief Executive e ty Chair: Marie Gabriel CBE Chief Executive: Antek Lejk Be Working together Trust Headquarters: Hellesdon Hospital, Drayton High Road, Norwich NR6 5BE “\~ for better mental health — Tet: 01603 421421 Fax: 01603 421341) www.nsft.nhs.uk
See every Prevention of Future Deaths report matching Norfolk and Suffolk NHS Foundation Trust, 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.