Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0088, written 13 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 | 13 Mar 2019 |
|---|---|
| Reference | 2019-0088 |
| Deceased | Tamsin Grundy |
| Coroner | Jacqueline Lake |
| Coroner area | Norfolk |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| 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.
Regulation 28: REPORT TO PREVENT FUTURE DEATHS
REGULATION 28 REPORT TO PREVENT DEATHS
THIS REPORT IS BEING SENT TO:
THE CHIEF EXECUTIVE
NORFOLK & SUFFOLK NHS FOUNDATION TRUST
HELLESDON HOSPITAL
DRAYTON HIGH ROAD
NORWICH
NR6 5BE
1 CORONER
{ am Jacqueline LAKE, Senior Coroner for the area of Norfolk
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.
| 4 CIRCUMSTANCES OF THE DEATH
3 INVESTIGATION and INQUEST
On 30/07/2018 | commenced an investigation into the death of Tamsin Rebecca Lianne GRUNDY aged 23.
The investigation concluded at the end of the inquest on 13/03/2019. The conclusion of the inquest was:
Suicide. The medical cause of death:
1a Compression of the Neck by a Weightlifting Bar
1b
1c
i]
Miss Grundy had a history of depression and had previously made attempts to end her own life. Miss
Grundy was under the care of the Mental Health Services at the time of her death. On 26 July 2018 Miss
Grundy was alone at home. She was later found with a weightlifting bar across her neck. Emergency
services were called and she was pronounced dead at the scene.
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.Miss Grundy repeatedly spoke about her concern about the number of people involved in her care,
particularly from the Crisis Resolution Home Treatment Team. It is understood Miss Grundy saw 25 plus
members of the Team in some 14 months. The evidence was that she found it difficult to relate to so many
people, having to repeat the difficulties she was experiencing which she felt was adversely impacting on her
mental health. It was not clear from the evidence that this issue was addressed during Miss Grundy’s
contact with the service. ;
2. This issue is referred to in the Serious Incident Requiring Investigation Report, having been raised by Miss
Grundy’s family, but there is no definitive, timed action arising from it and no named person responsible for
any such action.
6 ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and { 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 08 May 2019. |, 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.
[3 COPIES and PUBLICATION
| have sent a copy of my report to the Chief Coroner and to the following Interested Persons:
«2
Clinical Commissioning Group (West Norfolk)
who may find it useful or of interest.
tam 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 senda
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: 13/03/2019
Lhe
Jacqueline LAKE
Senior Coroner for Norfolk
Norfolk Coroner Service
Carrow House
301 King Street
Norwich NR12TN
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) Norfolk and Suffolk NHS Foundation Trust ~7 M Our Ref: JW/ML AY 2019 Trust Management Private and Confidential 1 Floor Admin Mrs J Lake Hellesdon Hospital Senior Coroner for Norfolk Drayton High Road Carrow House Hellesdon 301 King Street Norwich Norwich NR6 5BE NR1 2TN 3 May 2019 Dear Mrs Lake Re: Ms Tamsin Grundy | write in response to your prevention of future deaths report dated 13 March 2019 which followed the conclusion of the inquest into the death of Ms Tamsin Grundy. | know you will share a copy of this response with Ms Grundy’s family and | would like to express my condolences for their loss. Every death is a tragedy and the safety of those in our care is the Trust’s priority. Your report expressed Ms Grundy’s experience that she was concerned at the number of staff involved in her care, particularly during the time she was receiving contact from the Crisis Resolution and Home Treatment (CRHT) team, which was six months before her tragic death. Ms Grundy’s experience was that it was difficult to explain her circumstances on each occasion and to relate to so many people. Ms Grundy was in contact with the Trust’s Youth Service since 2016. She was allocated a staff member whose role was to coordinate her care. This member plays an important role in forming a therapeutic relationship with the service user, working together to implement plans to help respond to the individual’s needs. There are occasions where an individual’s need changes requiring a period of more intensive support which is provided by the Trust’s acute services. The CRHT provide intensive periods of support in the community for short periods, supplementing the care provided by the community team. This means the team have to be flexible and adaptable in approach requiring staff to work over a 24 hour period, seven days per week. Appointments with users may range from multiple contacts in a day to every few days. Given the team’s role in providing this enhanced contact it is a challenge to provide a model that would absolutely ensure an individual is guaranteed to see a limited number of staff. Notwithstanding this challenge, it was the expressed experience of Ms Grundy that having such numbers of staff involved made it difficult to form full therapeutic relationships. To support continued development of the service provided, the CRHT team is using a national 39 point fidelity scale to help it reflect on current practices identifying areas of focus and improvement. One of the points refers directly to this matter and the team are working to apply this on a consistent basis, using daily planning to match clinicians with individual visits where a positive therapeutic relationship has developed. The scale is being used more widely across the Trust. Thank you for raising this matter which has been of assistance to us. Yours sincerely we Olen - dont Jonathan Warren Chief Executive 2@, ‘ Chair: Marie Gabriel CBE Chief Executive: Jonathan Warren yee Working together Trust Headquarters: Hellesdon Hospital, Drayton High Road, Norwich NR6 5BE “ for better mental health Tel: 01603 421421 Fax: 01603 421341 www.nsft.nhs.uk
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