Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0042, written 11 Feb 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 11 Feb 2019 |
|---|---|
| Reference | 2019-0042 |
| Deceased | Robert Hughes |
| Coroner | Katy Skerrett |
| Coroner area | Gloucestershire |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths · Mental Health related deaths · Suicide (from 2015) |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
H M Senior Coroner for Gloucestershire Ms Katy Skerrett REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: (1) Shaun Clee, CEO, 2gether NHS Foundation Trust, Edward Jenner Court, 1010 Gloucester Business Park, Pioneer Avenue, Brockworth, Gloucester, GL3 4AW 1 CORONER I am Katy Skerrett, Senior Coroner for Gloucestershire. 2 CORONER’S LEGAL POWERS I 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 27th February 2018 I commenced an investigation into the death of Robert Glyn Hughes. The investigation concluded at the end of the inquest on the 29th January 2018. The conclusion of the inquest was suicide. The medical cause of death was 1A Hanging. 4 CIRCUMSTANCES OF DEATH Robert Glyn Hughes was a 67 year old man who lived alone. He had a long history of low mood, alcohol and diazepam dependence, and he had taken numerous overdoses in the past. He had been diagnosed with prostrate cancer and was struggling with the diagnosis and the side effects from the treatment. On the 26th January 2018 he took an overdose and was admitted to hospital. After treatment and assessment by the mental health liaison team he was discharged on the 30th January. On the 14th February 2018 Mr Hughes contacted the Crisis team expressing suicidal ideation. After a telephone assessment he agreed to contact his community mental health nurse, and his GP. On the 20th February 2018 the police were contacted by a concerned friend of Mr Hughes. Police attended at his property and forced entry. They found Mr Hughes hanging with a cord around his neck attached to the door in his bedroom. He was pronounced deceased at scene. Mr Hughes had left a suicide note in his living room. Police are satisfied there are no suspicious circumstances surrounding his death. CORONER’S CONCERNS 5 During the course of the inquest the evidence revealed a matter giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. Although it should be noted that I did not find this area of concern to be a causative factor in Mr Hughes’ case. In the circumstances it is my statutory duty to report to you. The MATTER OF CONCERN is as follows. – (1) The triangle of care approach, where mental health team practitioners seek permission from the patient to approach the patient’s family, is not consistently applied. 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. Gloucestershire Coroner's Court, Corinium Avenue, Barnwood, Gloucester, GL4 3DJ Tel 01452 305661 | coroner@gloucestershire.gov.uk 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 4pm 8th April 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 Chief Coroner and to the following Interested Persons (1) 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 coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. 9 Dated 11th February 2019 Signature_________________________ Ms K Skerrett Senior Coroner for Gloucestershire Gloucestershire Coroner's Court, Corinium Avenue, Barnwood, Gloucester, GL4 3DJ Tel 01452 305661 | coroner@gloucestershire.gov.uk
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.
2gether NHS Foundation Trust NHS Trust HQ Edward Jenner Court 1010 Pioneer Avenue Brockworth Gloucester GL3 4AW Direct Tel: 0300 421 7102 Website: wwvv.2qether.nhs.uk Ms K Skerrett Senior Coroner Gloucestershire Coroner's Court Corinium Avenue Gloucester GL4 3DJ 8th April 2019 Dear Ms Skerrett Re: Regulation 28 Report to Prevent Further Deaths - The Late Mr Robert Glyn Hughes Thank you for the notification of the Regulation 28 Report, which was issued to us on the 11th February 2019, following the inquest into the death of Mr Robert Glyn Hughes. It is always a sadness and of concern to us when someone who uses our services dies whilst in our care. We want to do all that we can to learn from the enquiry that has been undertaken into the death of Mr Hughes so that we can take action to improve our practice accordingly. Your report raises concern with us that the Triangle of Care approach, where mental health team practitioners seek permission from the patient to approach the patient's family, is not consistently applied'. We agree with you that there is more work for us to progress to ensure that our patient's family members become partners with us in the care of their loved one whenever possible. We regard this as a fundamental principle within our routine practice. We thought it helpful to outline some of our committed effort undertaken in recent years toward this goal, prior to offering you assurance that we will continue to strive for a more consistent application of this practice into the future. We recognise the need and benefits for our service users, their careers and our staff which can flow from us establishing a strong working partnership with family members in our delivery of care and support. In 2011, we published a Carers Charter which was developed with local people who both used our services and cared for people who used our services. This is published on our website, is still displayed in clinical settings, was launched at a Board level listening and learning event with local families and continues to be profiled throughout our work. Main office: Pioneer Avenue. Gloucester Business Park. Brockworth, Gloucester, Gloucestershire. GL3 4AW Chair: Ingrid Barker Chief Executive: Paul Roberts `gether is the name for 'gether NHS Foundation Trust Mental & Social Healthcare Our Triangle of Care membership started when the scheme was launched in 2015. Developing practice to be in line with the six standards expected in the Tringale of Care (https://www.nhsconfed.orqHmedia/Confederation/Files/publie/020access/CareTriangle.pdf) has been a dedicated practice development initiative, overseen at Executive level and its progress monitored by our Governance Committee, since that time. In 2016 and together with local carer organisations, we were acknowledged and commended by the Carers Trust for our progress in involving families in the care and support we offer to their loved ones. (https://www.2aethernhs.uk/commitment-to-carers-recounised-with-qold-star- award°. Since then we have undertaken further and additional practice development work with our clinical teams and the outcomes of this were recognised in 2018 with us receiving a second acknowledgement and commendation from The Carers Trust. This acknowledgement was in recognition of our progress demonstrated through a formal audit (httos://www.atethernhs.uk/commitment-to-carers-recoonised-with-qold-star-award/ ). We would be pleased to provide the documentation submitted to the Carers Trust to you should this be helpful. We remain committed to improving this area of our practice to ensure that families/carers are always involved with us in provided care and support to their loved one wherever possible and we will continue to do all that we can to make this a reality. In response to your report, we are proposing to progress the following to move towards this requirement: • Reinforce our aspirations and approach at one of our Senior Leaders Forum, with our Expert by Experience Carers. Our senior Leaders Forum brings together some 100+ of our service/team managers. In this Forum we discuss and involve our service/team managers in a number of strategic and practice matters and require them to be message and practice carriers up and down the organisation. We will undertake a session in relation to reinforcing the involvement of family and carers in the care and support we provide by May 2019 • Issue a further "Practice Note" from our Clinical Executives, to all clinical staff by June 2019 • Undertake a 'Carers Learning Update Week' event for clinical staff in July 2019 • Issue a blog for staff in relation to these issues from our Director of Quality by July 2019 • Include involvement of carers in our Always Event initiatives by September 2019 As part of our ongoing Quality Improvement work, led by our Director of Quality, we are progressing a project throughout 2019/20 to further our work to effectively embed lessons learned from serious incident investigations into clinical practice. We will be reporting this through our Trust Governance committee and to our Commissioners. This work will also be closely aligned to work that is under way in the county alongside Public Health colleagues and the CCG to reduce suicides, in line with national plans such as the Inpatient Zero Suicide initiative. Progress on this will also be reported to our Trust Governance committee, our Commissioners and NHS Improvement. Our efforts to engage with all those involved in a person's care remains a consistent thread throughout our services. We believe that communication and connections of the nature outlined above will contribute to improving patient safety and we will continue our work to ensure this culture in maintained and further developed in all parts of our organisation. Please do not hesitate to contact me for clarification in relation to any aspects of our proposals, or please feel free to call me if a conversation would be helpful. We trust that the above demonstrates that we have taken your notice seriously and are committed in trying to and improve our approach to hopefully reduce adverse outcomes from poor communications between clinicians and carers/families. Yours sincerely Colin Merker Deputy Chief Executive 2gether NHS Foundation Trust
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