Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0062, written 25 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 | 25 Jan 2019 |
|---|---|
| Reference | 2019-0062 |
| Deceased | David Squire |
| Coroner | Emma Serrano |
| Coroner area | Black Country |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths · Mental Health related deaths |
| 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: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. NHS England; and 2. The Chief Coroner 1 CORONER I am Emma Serrano, Assistant Coroner, for the coroner area of the Black Country. 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 1. On 30/07/2018 I commenced an investigation into the death of David Squire. The investigation concluded at the end of the inquest on the 23/01/19. 2. The conclusion of the inquest was misadventure. 3. The medical cause of death was 1a) Hanging by Ligature 4 CIRCUMSTANCES OF THE DEATH 1. On the 25/07/18 David Squire took his own life by hanging himself from a low bridge in Fibbersley Nature Reserve in Willenhall. David Squire was a detained patient having been detained under Section 2 of the Mental Health Act at a care home nearby called The Priory at Lakeside View Care Home. 2. During the course of the inquest evidence was heard as to David Squire’s admission to The Priory on the 22/7/18 under Section 2 of the Mental Health Act. This was because he had suicidal thoughts and thoughts of harming others. The Priory was, and still is, a non-smoking hospital in accordance with guidelines set down by NHS England. This states that all hospitals are to be non-smoking. Non-smoking meaning that no smoking is permitted on the premises or grounds of any hospital. The smoking area at The Priory was therefore located outside of the hospital grounds. 3. The Priory offers nicotine replacement to patients that smoke. For patients who refuse and want to smoke a cigarette, permission has to be 1 [IL1: PROTECT] obtained for escorted “off grounds” leave. This is called Section 17 leave. 4. On Tuesday 24/7/2018 David Squire was permitted to have escorted leave off of the grounds of the Priory Lakeside view, for a cigarette. When he had finished his cigarette he refused to come back to The Priory Lakesde View and left. ON the 25/7/18 he was found deceased at in Fibbersley Nature Reserve in Willenhall. 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. Evidence emerged during the inquest which pointed towards two areas of concerns regarding the NHS England Guidance regarding smoke-free hospitals: 1. This guidance does not permit the proper use of Section 17 leave. The Priory is a smoke free hospital in accordance with NHS England guidance and cannot have a smoking area on the hospital grounds. To allow patients to smoke, Section 17 leave is utilised outside of The Priory’s grounds. Section 17 leave should be used for many purposes, including patent observation and interaction and to assess whether they are a risk of absconding. Given that purpose, the process of leave is staged. Patients start with escorted leave within the grounds, then unescorted, then escorted leave off grounds and then unescorted. Patients, who refuse nicotine replacement medication, and continue to smoke, must start the staged leave at escorted “off grounds.” This is so The Priory can comply with the NHS England guidance. Smoking patents therefore start leave at “off grounds” without the staged process and level of observation that non-smoking patients would be offered. 2. The guidance fails to account for the differing needs regarding the different type of hospital that the policy spans. The application of the guidance to a standard NHS hospital creates far less of a risk than it does to a mental health hospital where it is accepted there is a frequency of patients who are at risk of absconding, self-harm and harm to others. The guidance leaves mental health hospitals, when detained patients smoke and refuse nicotine replacement therapy, to take detained patients off grounds in undesirable circumstances. The guidance, as it stands, with no tool to depart from the guidance, where necessary, leaves a significant risk. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. You may wish to consider the following: 1. The risk that the policy creates when considering hospitals that deal with patients that are detained under section; 2. Situations where the guidance may be departed from; 2 [IL1: PROTECT] 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 15 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. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: 1. The family of David Squire; 2. West Midlands Police; and 3. The Priory at Lakeside View 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 25 January 2018 Miss Emma Serrano Assistant Coroner Black Country Area 3 [IL1: PROTECT]
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.
NHS} England Professor Stephen Powis National Medical Director Miss Emma Serrano 6 Floor, Skipton House Assistant Coroner 80 London Road Black Country Area SE1 6LH Jack Judge House Halesowen Street Oldbury West Midlands S april 2019 B69 2AJ Dear Miss Serrano, Re: Regulation 28 Report to Prevent Future Deaths — David Squire — 25 July 2018 Thank you for your Regulation 28 Report (hereinafter ‘report’) issued on 25 January 2019 following the inquest into the death of David Squire on 25 July 2018. | would like to begin by expressing my deep condolences to David Squire’s family. | am aware that the conclusion of the recent inquest was misadventure with David Squire's death found to be the result of hanging by ligature. Following the inquest, you raised concerns in your report regarding NHS England's guidance on smoke-free hospitals and in particular when applied to mental health hospitals dealing with detained patients, and their specific use of section 17 leave. | can confirm that NHS England, in collaboration with Public Health England (PHE), is working to reduce very high smoking rates in people with severe mental iliness and, following the publication of the ‘Five Year Forward View for Mental Health’ in February 2016, a commitment was made to deliver smoke-free mental! health inpatient units and facilities by 2018. As part of going ‘smoke-free’ trusts are ensuring the implementation of NICE guidance PH48 and PH45 to ensure access to a full range of evidence-based treatment options to support quitting smoking or temporary abstinence for both patients and staff. When a service user is admitted to a smoke-free inpatient mental health service, they should be supported to stop smoking or to reduce smoking in the longer term, or, where they do not wish to stop or reduce smoking, they should be supported to temporarily abstain from smoking for the duration of their admission. The NICE guidelines state that the use of Nicotine Replacement Therapy, in conjunction with behavioural therapy from trained staff, should be available within a timely manner. Further the PHE guidance to support the implementation of the smoke-free mental health trust policy highlights that smoke-free policies must be complemented by the ready availability of smoking cessation programmes and training, with robust implementation engagement strategies with staff and service users recommended. High quality care for all, now and for future generations In addition to the PHE guidance, the Mental Health Act Code of Practice published by the Department of Health in 2015 (the statutory guidance for providers of mental health services) sets out that leave of absence can be an important part of a person's care plan. The Code of Practice advises that when considering and planning leave of absence, responsible clinicians should, among other issues, consider the benefits and any risks to the patient's health (both mental and physical) and safety of granting or refusing leave. This is a complex area and the Code of Practice sets out that responsible clinicians should also, of course, take account of the patient's wishes and consider the benefits of granting leave for facilitating the patient’s recovery. In response to your request for further consideration | can confirm NHS England will raise the complexity of this issue with the Department of Health & Social Care as part of its contributions to the government-led response to the Independent Review of the Mental Health Act that reported to the Prime Minister in December 2018. The government has signalled its intention to legislate in response to the review, and NHS England will suggest that the issue of smoking and use of section 17 leave should also be considered as part of future revisions to the Code of Practice. Admittedly, although there is variation in how fully mental health trusts have implemented smoke-free policies across the country, there are a number of examples of successful and safe implementation and NHS England will continue to work alongside PHE to address the stark physical health inequalities experienced by people with mental health problems. To this end and in response to the House of Commons Science and Technology Committee’s recommendation, NHS England and NHS Improvement are developing guidance on the use of electronic cigarettes for providers of NHS care (with a specific focus on mental health facilities). This is being developed in conjunction with trusts, clinicians and patient groups to help reduce any disparity in access to electronic cigarettes and to give a real alternative to patients for whom traditional nicotine replacement therapies have failed. We intend to publish this guidance in Spring 2019 and will provide you with a copy for your information. Thank you for bringing these important patient safety issues to my attention. | hope the information above addresses the concerns you have raised within your report and provides you with the assurances that you requested. If you require any further information please do not hesitate to contact me. Yours sincerely (U nw! Professor Stephen Powis National Medical Director NHS England and NHS Improvement High quality care for all, now and for future generations
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