Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0013, written 10 Jan 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 10 Jan 2019 |
|---|---|
| Reference | 2019-0013 |
| Deceased | Christopher Seal |
| Coroner | Maria Voisin |
| Coroner area | Avon |
| Category | Community health care · Mental Health related deaths |
| Organisation named | Avon and Wiltshire Mental Health Partnership NHS 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.
M. E. Voisin Her Majesty’s Senior Coroner Area of Avon 10th January 2019 REF: 8714 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Chief Executive Avon & Wiltshire Mental Health Partnership NHS Trust 1 CORONER lam Maria Eileen Voisin Senior Coroner for the Area of Avon 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 03/01/2018 | commenced an investigation into the death of Christopher Michael SEAL. The investigation concluded at the end of the inquest. The conclusion of the inquest was Christopher Seal died on 30th November 2017 at the playing fields, Bath Spa University, Newton St Loe, Bath. He had placed a rope around his neck and was found suspended from the rugby posts, he had intended to take his own life. 4 CIRCUMSTANCES OF THE DEATH the mental health team. On 26" and 27" November Chris had been assessed as high risk and the plan was to assess him in the community as he indicated he was willing to engage. On 27" and 28" November he failed to respond to calls and disengaged from the service. On 29" November he cut his wrist and was assessed as high risk again by the mental health liaison team at the hospital and the plan remained the same, there was an underestimation of his condition at this assessment. Chris failed to be at home for the assessment immediately following his discharge. A welfare call to the police was made but the important information from the police following the welfare check was not relayed to the team or recorded in the records as it should have been. The cold call to Chris’s property on 30" November resulted in the only action of leaving a letter with another appaintment; there was no escalation as suggested in the “no response and police welfare check requests procedure” which is only a guide for patients in primary care as no policy exists. Finally there was no contact made with the family during 29" or 30" due toa poorly completed information sharing form. Chris’s death was due to suicide. However in the 5 days leading up to his death he was under the care of Telephone 01275 461920 Email AvonCoronersTeam @bristol.gcsx.gov.uk Website www.avon-coroner.com The Coroner's Court, Old Weston Road, Flax Bourton, BS48 1UL 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. The information sharing form — in this case it was not explicit as to whom information could be shared with hence the family were not informed or contacted; is there an issue with the form itself to make this clearer for clinicians to be more explicit or is there a training issue for the staff involved with completing this form? 2. On the RIO records system I was advised that it put the first information sharing form as the most recent when it wasn’t, in this case there was a more recent form, this misled the staff, although both, forms were clearly completed and on the RIO system — is this a technical matter with IT or is this a training matter for the staff using the system? 3. There were no next of kin details recorded on RIO —! was told that you use The National Spine to automatically populate this information however the next of kin details were on the hospital records for the A&E attendance and | was told that they use The National Spine. Is this system being used properly? 4. The demographics page in RIO — in this case it was incomplete and | was told it often is — is this training issue for the staff or again a technical matter with the RIO system? 5. | was told that there is no “no response policy” for those in primary care; that the policy which exists is for secondary or tertiary care and is therefore not applicable to the service users or staff in primary care. This would also raise the question of training 6. | was told that there is no “welfare check policy” for those in primary care; that the policy which exists is for secondary or tertiary care and is therefore not applicable to the service users or staff in primary care. | was told that Avon and Somerset Constabulary are in the process of writing a “welfare check policy” and it may be beneficial for there to be liaison with the police forces in the AWP area to ensure that any new policy that you consider is appropriate is in line with their expectations as to what a police officer can and will do following such a call. This would also raise the question of training. 7. RIO entries generally — | was told that there is an expectation that staff are expected to make their entry onto the RIO system within either 72 hrs. or 24hrs. Is this in line with what professional bodies expect and should it be? 8. The intensive service switchboard — is there an issue in relation to the training of staff and their ability to react to protecting life? | was told they do not have ability to call 999 but that they advise the service user to make the call, is that appropriate? 9. Contact with service user —| was told that the preferred method is verbal contact and the only other means is a text message with this being care planned. In this changing world of communication should other care planned options be considered such as email or messaging? Telephone 01275 461920 Email AvonCoronersTeam @bristol.gcsx.gov.uk Website www.avon-coroner.com The Coroner's Court, Old Weston Road, Flax Bourton, BS48 1UL 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. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by a March 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: a. father of deceased HB — mother of deceased Royal United Hospital, Bath 1am 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. 10/01/2019 Signature _— M a ior Coroner Area of Avon Telephone 01275 461920 Email AvonCoronersTeam @bristol.gcsx.gov.uk Website www.avon-coroner.com The Coroner's Court, Old Weston Road, Flax Bourton, BS48 1UL
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.
Ms M. E. Voisin, Senior Coroner, Area of Avon Avon Coroner’s Court, Old Weston Road, Flax Bourton, Avon, BS48 1UL Date: 6 March 2019 Reference: 8714 Dear Ms Voisin, Bath NHS House Newbridge Hill Bath BA1 3QE Tel Email I am writing in response to the Regulation 28 Prevention of Future Deaths report received in connection with the death of Mr Christopher Michael Seal. I welcome the opportunity to respond to the issues you have raised and improve the safety of our services for patients and families. I will respond to each of the issues in turn. The information sharing form Immediate action has been taken regarding the current ‘Consent to Share’ form in use across the Trust. This has been discussed at local Quality and Standards meeting and the Learning from Experience Forum, where key learning from the untimely death of Mr Seal has been shared and disseminated. It has been emphasised that all staff need to record explicit consent, i.e. stating what information can be shared, with whom and what their contact details are. The Trust recognises that the consent to share information form could and should be clearer, as could the staff guidance. In light of the General Data Protection Regulation (GDPR), the Governance Team are now reviewing the Trust’s consent to share information procedures. Once they have ensured that the framework is compliant with GDPR, we then will proceed with making the recording and retrieval of consent to share is in place and the clinical processes, supporting guidance, recording processes and information presentation will be improved, aligned and communicated by the end of June 2019. We are also working with the Senior Practitioner for Family Interventions to provide staff training regarding involving relatives and carers, including working with service users who might initially be reluctant to allow this but may change their views over time. Furthermore, the Trust is engaged with year long improvement programme with ‘Making Families Count’ initiative, set up by NHS England, collaborating to improve families’ involvement in mental health services and ensure that learning from their experience is used to improve services and reduce avoidable harm. This family led group has delivered two sessions to Trust staff already, the most recent in February 2019. Chair Charlotte Hitchings Trust Headquarters Bath NHS House, Newbridge Hill, Bath BA1 3QE Chief Executive Dr Hayley Richards __________________________________________________________________________ _____ 'We are a teaching, learning and research trust; we aim to inform you about relevant opportunities, unless you tell us otherwise.' Date of amended information entered onto RiO records system The Trust recognises the confusion this caused staff and indeed the Court and we welcome the fact that this has been highlighted for improvement. The training and guidance for staff has consequently been amended. The RiO clinical support now states that it is acceptable to either edit the most recent RiO form, or to create a new form. It is not acceptable to edit forms other than the most recent. This has been disseminated to clinical staff through team meetings and is being circulated to staff via an internal ‘Red Top Alert’. Next of Kin details recorded on RiO and link to National Spine This issue has helped us identify that we need to improve the way we synchronise our mental health records at the Trust in order to connect with the National Spine. When we first register a service user, the electronic patient records system, RiO, synchronises with the National Spine. Each time the record is accessed following this, RiO checks with the National Spine and if differences are noted, the user is asked to accept or reject changes. If a response is not given, this means that anomalies are not resolved or information is incomplete. The Trust is working to find a technical solution to create a work list of records that require synchronisation in order that administrative staff might be able to complete this task and improve compliance (target completion date 31 August 2019). There is a secondary issue that where there is no Next of Kin recorded, the absence of this is not evident. There is presently a development request to place an indicator on the front screen of the record showing the Next of Kin/In Case of Emergency contact, or the absence of that record in red, in order to make this more obvious to the clinician/user (target completion date 31 July 2019). The demographics page on RiO Staff have been reminded what the minimum information requirement is, and that this includes completion of the demographics page. A random selection of patient records are audited monthly and team managers have been made aware that completed demographic information is a requirement for all staff. Lack of “No Response policy” for those in primary care. The ‘No Response’ Policy is applicable to secondary and tertiary care. The policy states that for patients in primary care, the GP is informed of the lack of response to a planned visit. A planned visit is taken to mean planned and agreed between the staff member and the service user. Discussions have been held with the GP Mental Health Lead who has reinforced the expectation that the need to inform that GPs will be based on clinical judgement of staff involved. The expectation is that AWP would assess the risk based on all the available evidence, and alert the GP where appropriate, i.e. when risk or likely risk is increased. No “welfare check policy” for those in primary care AWP have contacted Avon and Somerset Police to request close liaison and joint working regarding their ‘Welfare Check Policy’ to ensure understanding and expectations are aligned. The local representative for the Avon & Somerset Crisis Concordat will maintain close follow Chair Charlotte Hitchings Trust Headquarters Bath NHS House, Newbridge Hill, Bath BA1 3QE Chief Executive Dr Hayley Richards __________________________________________________________________________ _____ 'We are a teaching, learning and research trust; we aim to inform you about relevant opportunities, unless you tell us otherwise.' up on this at these meetings or directly with the Police Mental Health Liaison Officer. In addition, the police are holding a conference in March 2019 with the theme “What information we should be sharing relating to a person’s mental health concerns and, how/with whom to best manage risk?" They are looking at exploring: What is the scale of the demand/risk at the moment – for police and partners? What are the risks to the lack of communication of these concerns from one agency to another? What information should be gathered/shared by the police - how and with who? What are the consent considerations? How are a patient’s care and support needs best identified and addressed? AWP BaNES will engage with this forum and we welcome the opportunity for further joint working. Timeliness of RiO entries AWP’s guidance is that for Inpatient, Intensive and Outpatient records should be completed in real time – in practice, this may mean by the end of the shift, hence up to 24 hours. For the community services the recording period may increase to 72 hours in some circumstances. It is expected that a consideration of risk would inform any decision to delay writing entries. Guidance for staff is located on the Trust intranet and is attached as Appendix 1 below. Trust guidance is in line with what professional bodies expect of their staff. NMC Code of Conduct, states: “10.1 complete all records at the time or as soon as possible after an event, recording if the notes are written some time after the event.” HCPC Standards of Conduct, Performance and Ethics state “10.2 You must complete all records promptly and as soon as possible after providing care, treatment or other services.” College of OT Code of Ethics and Professional Conduct states: “2.6.1 You must accurately and legibly record all information related to your involvement with the service user, as soon as practically possible after the activity, in line with the standards of the Health and Care Professions Council, the College of Occupational Therapists and local policy. Any record must be clearly dated, timed and attributable to the person making the entry.” British Association for Social Work and Social Workers states: “11. Maintaining clear and accurate records: Social workers should maintain clear, impartial and accurate records and provision of evidence to support professional judgements. They should record only relevant matters and specify the source of information.” The intensive service switchboard and their ability to react to protecting life I apologise that the evidence given by Ms Spaull indicated that the AWP switchboard does not have the ability to call 999 in an emergency but advise the service user to make the call; this is Chair Charlotte Hitchings Trust Headquarters Bath NHS House, Newbridge Hill, Bath BA1 3QE Chief Executive Dr Hayley Richards __________________________________________________________________________ _____ 'We are a teaching, learning and research trust; we aim to inform you about relevant opportunities, unless you tell us otherwise.' incorrect. The switchboard can and do call 999, as appropriate, when an emergency situation requires this. Methods of contact with service user AWP has local procedures for text access for people who are deaf or hard of hearing. It is recognised that some service users, regardless of disability, may prefer forms of communication other than phone calls. Where this is indicated an Individualised approach to communication with the service users will be considered and planned. However, e-mail or texting high risk information is not always suitable as information can be missed or there can be technical risks. The Trust has ensured that all staff are aware of the individualised communication options and that they are suitably able to have appropriate conversations with service users about the risks of various communication methods The Trust policy is that only NHS.net to NHS.net emailing is secure. Social media use such as Facebook messaging and Whatsapp are not used because of risks to information governance, particularly confidentiality. I hope the information provided indicates how seriously the Trust has taken the death of Mr Seal and how committed we are to embedding the learning, improving patient safety and reducing avoidable harm. If there is any further information you require we would be happy to provide this. Yours sincerely Dr Hayley Richards, MRCGP; MRCPsych Chief Executive Avon and Wiltshire Mental Health Partnership NHS Trust Chair Charlotte Hitchings Trust Headquarters Bath NHS House, Newbridge Hill, Bath BA1 3QE Chief Executive Dr Hayley Richards __________________________________________________________________________ _____ 'We are a teaching, learning and research trust; we aim to inform you about relevant opportunities, unless you tell us otherwise.'
See every Prevention of Future Deaths report matching Avon and Wiltshire Mental Health Partnership NHS 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.