Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0084, written 8 Mar 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 8 Mar 2019 |
|---|---|
| Reference | 2019-0084 |
| Deceased | John Richardson |
| Coroner | Penelope Schofield |
| Coroner area | West Sussex |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Sussex Partnership 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: REPORT TO PREVENT FUTURE DEATHS
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
Sam Allen
Chief Executive
Sussex Partnership NHS FoundationTrust
Swandean
Arundel Road
Worthing
West Sussex
BN13 3EP
1
CORONER
I am PENELOPE SCHOFIELD, senior coroner, for the coroner area of WEST SUSSEX
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 4th February 2018, I commenced an investigation into the death of John Peter
RICHARDSON, aged 60 years. The investigation concluded at the end of the inquest on
the 18th December 2018. The Inquest was held with a Jury and they provided the
following Narrative conclusion.
Since the 15th January 2018, John Richardson had been an informal patient at Maple
Ward, Meadowfield Hospital, Worthing; being treated for Recurrent Depressive Disorder
and Adjustment Disorder with suicidal thoughts. Although we acknowledge John
Richardson intended to take his own life and was admitted as a voluntary patient, we
conclude that he did not receive adequate support in a number of areas which could
have prevented the circumstances leading to his death. We fully agree with Lorraine
Biddell’s serious incident review in which she identified 9 key failings; we particularly
draw attention to the following: after the initial 72hr care plan, no risk assessment or
further care plan was formally created, recorded or communicated for John Richardson;
this was not addressed during his stay. Poor oral and written communication and a lack
of clarity within that communication, in handovers, care notes and accompanying
documents, caused confusion amongst staff and eventually with police following his
disappearance. Additionally, minimal communication was made with his family. There
was poor record keeping and understanding of trust policy, particularly regarding specific
failures to address John Richardson’s ongoing risk, the plans for his care, his leave
arrangements and the significant events on the 3rd February.
4
CIRCUMSTANCES OF THE DEATH
On 15th January 2018, John Peter Richardson (known as Sean) was admitted as a
voluntary patient to Meadowfields Hospital. At the time of his admission he had been
having suicidal thoughts. At about 10.20am on the 3rd February 2018 Sean had gone out
for a walk in the grounds but he did not return. Staff at Meadowfields contacted Police
at 1.06pm to report Sean as a missing person. The Police attempted to locate him but
without success. On 4th February 2018 a member of public was walking their dog in
some woodlands in Patching when they came across the body of Mr Richardson. Police
1
and ambulance were called and death was confirmed by paramedics at 11:09am at the
scene. Mr Richardson was found lying on his right side with a ligature around his neck,
above him was the other part of the ligature tied around the branch of a tree which
appears to have snapped at some point. Police confirmed no suspicious circumstances
and no third party involvement.
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) The Jury in their Narrative Conclusion confirmed that they agreed with the
findings in the Serious Incident Report compiled by
and the 9
key failings by the Trust. However I am satisfied that since John Richardson’s
death measures appear to have been put in place to address all these issues.
(2) However the death of Mr Richardson appears to have occurred when there was
some confusion amongst staff with regards to Mr Richardson’s leave status.
This was identified by the Jury in their conclusion. Whilst some guidance is
provided to staff, with regards to voluntary patients taking leave, there is no
specific Leave Policy for Voluntary Patients in the same way as there is one for
those patients sectioned under the Mental Health Act.
6
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe your
organisation has the power to take such action.
7
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report,
namely by 3rd May 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:-
The family of John Peter Richardson
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
8th March 2019
Penelope Schofield, Senior Coroner
2
West Sussex Coroners Office
County Record Office
Orchard Street
Chichester
PO19 1DD
Tel: 0330 2227100
Email: hm.coroner@westsussex.gov.uk
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.
A member of: NHS| Association of UK University Hospitals Sussex Partnership NHS Foundation Trust Swandean Arundel Road 3 May 2019 07 MAY 2019 Worthing West Sussex Ms Penelope Schofield BN13 3EP Senior Coroner for West Sussex County Record Office Orchard Street Chichester West Sussex PO19 1DD Dear Ms Schofield Re: Inquest into the death of John Peter Richardson Thank you for your letter dated 8 March 2019 enclosing your Report to Prevent Future Deaths under Regulation 28 Coroners (Investigations) Regulations 2013. | write to formally respond and to provide you with details of the action taken by the Trust as a result of the concern that you have raised. Following Mr Richardson’s tragic death, the Serious Incident Investigator, Lorrainne Biddle, met with me to go through all the failings she identified. She did this because of the level of her concern, because she knew that | would want oversight and so that | could contact the family at the earliest opportunity. | was pleased to hear that the Jury agreed with her findings and that you were satisfied with the measures that we put in place to address matters. This was a particularly sad case and | have, since the Inquest, met with Mr Richardson’s wife and one of his daughters to offer a personal apology and provide ongoing assurance as to the actions that have been taken. Following receipt of your letter, we have given considerable further thought as to how best we might improve our staff's understanding of the principles to be followed when voluntary patients leave the wards. The decision we have taken is to include guidance in our new Acute Care Operational Policy. | have enclosed a copy of that guidance for your information. As you will see, it covers both s.17 leave as well as the principles that need to be applied to voluntary patients. Presenting the guidance in this way was considered to be preferable to any further ‘stand alone policy. It is hoped that this will be highly accessible and provide immediate access to the key principles, coupled with signposting to other documents if more information is required. Chair: Peter Molyneux Chief Executive: Samantha Allen Head office: Sussex Partnership NHS Foundation Trust, Swandean, Arundel Road, Worthing, West Sussex, BN13 3EP www.sussexpartnership.nhs.uk A teaching trust of Brighton and Sussex Medical School | hope that the content of the enclosed addresses your concern and provides you with complete reassurance. However, if any further clarification is required or | can assist further in any way then please do not hesitate to contact me. Yours sincerely Samantha Allen Chief Executive
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