Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0410, written 17 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 | 17 Dec 2018 |
|---|---|
| Reference | 2018-0410 |
| Deceased | Agnes Lambert |
| Coroner | Mary Hassell |
| Coroner area | Inner North London |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Camden and Islington NHS Foundation Trust |
| 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: Prevention of Future Deaths report
Agnes Stephanie LAMBERT (died 30.06.18)
THIS REPORT IS BEING SENT TO:
1. Ms Wendy Wallace
Chief Executive
Camden & Islington NHS Foundation Trust (C&I)
4th Floor, East Wing
St Pancras Hospital
4 St Pancras Way
London NW1 0PE
1
CORONER
I am: Coroner ME Hassell
Senior Coroner
Inner North London
St Pancras Coroner’s Court
Camley Street
London N1C 4PP
2
CORONER’S LEGAL POWERS
I make this report under the Coroners and Justice Act 2009,
paragraph 7, Schedule 5, and
The Coroners (Investigations) Regulations 2013,
regulations 28 and 29.
3
INVESTIGATION and INQUEST
On 3 July 2018, I commenced an investigation into the death Agnes
Stephanie LAMBERT. The investigation concluded at the end of the
inquest earlier today. I made a determination of suicide at inquest. The
medical cause of death was 1a) suspension by ligature.
4
CIRCUMSTANCES OF THE DEATH
Agnes Lambert was a mental health nurse working at Highgate Mental
Health Centre. Following allegations that she had failed to follow a direct
instruction not to engage with a patient who was fixated on her, and that
she had entered his room at night without telling other members of staff,
she was investigated by the trust in the six months preceding her death.
1
The investigation had been concluded by the time of Ms Lambert’s death
and she was just about to return to work, but a day or two before she
died she was very upset by a colleague’s remark that everyone at
Highgate knew of the allegations and believed them.
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.
1. Two weeks before
the allegations were made and
the
investigation began (i.e. two weeks before the occasion of Nurse
Lambert entering the patient’s room), the patient in question
argued with another patient whom he thought was stealing his
fiancée. He and Nurse Lambert were not engaged. They were
not in a romantic relationship.
The more senior member of staff who dealt with the matter,
recognised the patient’s fixation and thought that Agnes Lambert
should move to work on another ward. However, when Nurse
Lambert declined because she did not regard the matter as
serious, the manager, who had seniority and more experience, did
not insist.
The service manager who gave evidence in court accepted that
the move should have been made regardless of the staff nurse’s
wishes. If it had been, Nurse Lambert would not have been in a
position to enter the patient’s room a fortnight later.
2. Following the allegations, it then took the trust four months (rather
than the expected four weeks) to interview eight witnesses in
order to progress to a disciplinary hearing. This was a distressing
time for Ms Lambert and she finally went on sick leave.
The service manager who gave evidence in court agreed that this
was an unacceptable delay.
6
ACTION SHOULD BE TAKEN
In my opinion, action should be taken to prevent future deaths and I
believe that you have the power to take such action.
2
7
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date
of this report, namely by 18 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.
8
COPIES and PUBLICATION
I have sent a copy of my report to the following.
HHJ Mark Lucraft QC, the Chief Coroner of England & Wales
Care Quality Commission for England
Agnes Lambert’s parents
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 Senior Coroner, at the time of your response,
about the release or the publication of your response by the Chief
Coroner.
9
DATE SIGNED BY SENIOR CORONER
17.12.18
3
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
Camden and Islington
NHS Foundation Trust
Executive office
4" Floor, East Wing
St Pancras Hospital
4 St Pancras Way
London NW1 OPE
Tel: 020 3317 706
www.candi.nhs.uk
13 February 2019
Private and Confidential
Senior Coroner ME Hassell
Inner North London
St Pancras Coroner’s Court
Camley Street
LONDON N1C 4PP
Dear Coroner Hassell
Re: Prevention of future deaths report - inquest concerning the death of Agnes
Stephanie Lambert
lam writing further to the conclusion of this inquest that took place on 17 December 2018
and the subsequent Prevention of Future Deaths report that was issued to the Trust.
Agnes Lambert was employed by the Trust as a mental health nurse based at Highgate
Mental Health Centre. In the months prior to her death, an issue had arisen in regard to a
patient who had become fixated on her and it was alleged that she had entered his room at
night without telling other members of staff. A disciplinary investigation was commissioned
and Ms Lambert was informed on 12 April that the case would proceed to a formal hearing.
At this point, Ms Lambert went on sick leave, returning to work on 19 June, following the
disciplinary hearing which took place on 29 May 2018. Ms Lambert’s death was reported to
the Trust on 2 July 2018. The matters of concern that arose from the inquest were as
follows:
1. Prior to the allegations of Ms Lambert entering the patient’s room, a more senior staff
member recognised the patient’s fixation and requested that she be temporarily
redeployed to work on another ward. She declined and the manager did not insist on
this redeployment. At the hearing, the Senior Service Manager who gave evidence,
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accepted that the temporary redeployment to another ward should have been made
regardless of Ms Lambert’s wishes. If this had been executed, she would not have been
in a position to enter the patient’s room later.
2. Following the allegations, the investigation process took four months to interview eight
witnesses in order to progress to a disciplinary hearing. This was obviously a distressing
time for Ms Lambert and at the point that the decision was made to progress to a
hearing, she went on sick leave. The Senior Service Manager who gave evidence in court
agreed that the lengthy process was unacceptable.
You requested that we respond by 18 February 2019 to inform you of our intended actions.
Thank you for highlighting these issues which have subsequently been discussed and
reflected on at a number of forums between the operational teams involved and HR & OD.
We are committed to learning from Ms Lambert’s tragic death and promote to staff that the
Trust is a just and fair place to work.
Firstly, it is recognised that at the time that these events began, the ward where Ms
Lambert worked did not have a permanent ward manager in post and the overall
management and supervision structure on the ward was not as robust as it should have
been. Significant steps have since been taken to address this and there is now a permanent
ward manager. Further, we have recognised that there is a general need among managers
for further support around how to have challenging conversations with staff, particularly in
situations such as this, where the intention is not to punish the staff member, but to ensure
their safety, whilst making it clear that staff are expected to follow reasonable management
instructions. To support this, we are in the process of rolling out ‘vital conversations’
training which will form part of the professional requirements for all line managers in the
Trust, though nursing managers will initially be prioritised.
We absolutely recognise that unnecessary and lengthy disciplinary processes can have a
serious detrimental impact on staff mental health and wellbeing. With this in mind, the
disciplinary policy is currently being reviewed to include clearer criteria as to what does or
does not warrant a full investigation. We also have an added step in our disciplinary process
whereby a specially-trained lay member of staff reviews cases to gain assurance or indeed
challenge that a formal hearing is required. It is expected that this change along with the
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Vital Conversations training, will facilitate more issues being resolved informally through the
supervision process. For those investigations that do proceed formally, there will be a
greater focus on managers’ responsibility to minimise delay/keep to timeframes, and
monitoring to ensure that managers have offered/referred staff to occupational health for
support and also made them aware of our Employee Assist Programme. The refreshed
policy is expected to complete in March 2019.
The risks posed by unnecessary and lengthy disciplinary processes have been added to the
HR & OD department risk register to monitor and ensure progress is made.
| hope that my response provides you with the necessary assurance. If you need any further
information please do not hesitate to contact me.
H {U0
Angela! McNab
Chief Executive
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