Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0090, written 25 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 | 25 Mar 2019 |
|---|---|
| Reference | 2019-0090 |
| Deceased | Nora Bruton |
| Coroner | Adam Hodson |
| Coroner area | Birmingham and Solihull |
| Category | Alcohol, drug and medication related deaths · Mental Health related deaths · Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Birmingham and Solihull Mental Health 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 THIS REPORT IS BEING SENT TO: 1) CHIEF EXECUTIVE OF BIRMINGHAM & SOLIHULL MENTAL HEALTH FOUNDATION TRUST 1 CORONER I am Adam Hodson Assistant Coroner for Birmingham and Solihull 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 17/01/2019 I commenced an investigation into the death of Nora Theresa Bruton. The investigation concluded at the end of an inquest on 22nd March 2019. The conclusion of the inquest was a narrative conclusion as follows: Death was by drowning whilst under the influence of alcohol. It was not known how the deceased came to be in the water, nor was it known what her intention was when she entered. Her mental health had declined, which was contributed to by gaps in her care, but it was likely her death could not have been prevented. The medical cause of death was: 1a) DROWNING 1b) ALCOHOL INTOXICATION 4 CIRCUMSTANCES OF THE DEATH On 15/11/2018, Nora Bruton was found face down in a pond in Babbs Mill Park, Kinghurst, Birmingham by a member of the public who summoned the emergency services, but who subsequently declared her deceased at the scene. Post-mortem and toxicological evidence indicate that her death was from drowning, and that she was under the influence of alcohol at the time of her death. The deceased had a long-standing history of alcohol dependence syndrome and mixed anxiety and depressive disease and was under the care of mental health services. The evidence indicates that there was insufficient assessment and formulation around the impact of increased alcohol on her suicidal thinking and risk to self, as well as there being other contributory factors such as lack of referral to Addiction Services and a lack of communication and accurate recording of crisis calls between the Home Treatment Team and the Community Mental Health Team.. 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. A recommendation contained within the RCA report to carry out a review of the Clinical Risk Assessment training to incorporate clear risk formulation and management around harmful substance abuse, had been carried out, but this has had not been adequately disseminated to clinicians on the ground. Consideration therefore should be given to ensuring proper dissemination of this revised training to all treating clinicians as a matter of urgency; 2. A review of the protocol for communicating crisis calls to all teams involved in care delivery to ensure a robust system of communication has not been acted upon. I heard evidence that prior to Nora’s death there had been two separate incidents which led to significant patient harm and/or death which involved gaps in crisis call communication. Consideration should be given to ensuring this review takes place and the protocol appropriately modified as a matter of urgency; 3. I heard evidence that the Home Treatment Team model was undergoing a process of review and overhaul, and that this process had taken approximately 18 months to date but there was no estimate of when this would be completed by. Consideration should therefore be given as to ensuring that this review is concluded as a matter of urgency and any changes to the Home Treatment Team model are implemented with similar urgency. 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. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 20th 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: 1) Next of Kin / family 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 25/03/2019 Signature Adam Hodson Assistant Coroner Birmingham and Solihull
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.
Private & Confidential
Mr Adam Hodson
Assistant Coroner for Birmingham and Solihull
Coronors Office
Birmingham
UK
Chief Executive’s Office
Unit 1, B1,
50 Summer Hill Road
Birmingham
B1 3RB
Email:
Date: 20th May 2019
REGULATION 28 REPORT FOLLOWING THE DEATH OF NORA THERESA BRUTON
Dear Mr Hodson
May I please open this letter by expressing my sincere condolences to the family of Nora Bruton and
thank you for highlighting your areas of concern to me in relation to the care she received. We have
taken your comments very seriously and I detail below a number of actions taken which I hope will
prevent future deaths of this nature.
On 17/01/2019 you commenced an investigation into the death of Nora Theresa Bruton. The
investigation concluded at the end of an inquest on 22nd March 2019. The conclusion of the inquest
was a narrative conclusion as follows:
‘Death was by drowning whilst under the influence of alcohol. It was not known how the deceased came
to be in the water, nor was it known what her intention was when she entered. Her mental health had
declined, which was contributed to by gaps in her care, but it was likely her death could not have been
prevented’.
The medical cause of death was confirmed as:
1a) DROWNING
1b) ALCOHOL INTOXICATION
On 15/11/2018, Nora Bruton was found face down in a pond in Babbs Mill Park, Kinghurst, Birmingham
by a member of the public who summoned the emergency services, but who subsequently declared her
deceased at the scene. Post-mortem and toxicological evidence indicate that her death was from
drowning, and that she was under the influence of alcohol at the time of her death. The deceased had
a long-standing history of alcohol dependence syndrome and mixed anxiety and depressive disease
and was under the care of mental health services. The evidence indicates that there was insufficient
assessment and formulation around the impact of increased alcohol on her suicidal thinking and risk to
self, as well as there being other contributory factors such as lack of referral to Addiction Services and a
lack of communication and accurate recording of crisis calls between the Home Treatment Team and
the Community Mental Health Team.
Chair: Sue Davis, CBE
Chief Executive: John Short
Customer Relations Mon – Fri, 8am – 8pm Tel: 0800 953 0045 Text: 07985 883 509
Email: bsmhft.customerrelations@nhs.net Website: www.bsmhft.nhs.uk
The MATTERS OF CONCERN that you have raised are as follows. –
A recommendation contained within the RCA report to carry out a review of the Clinical Risk
1.
Assessment training to incorporate clear risk formulation and management around harmful substance
abuse, had been carried out, but this has had not been adequately disseminated to clinicians on the
ground. Consideration therefore should be given to ensuring proper dissemination of this revised
training to all treating clinicians as a matter of urgency;
I am able to confirm that a working group has now been established to devise a pilot of reviewed clinical
risk training both in terms of content and the way it is delivered. We are in the final editorial stages of a
new Dual diagnosis policy which will be launched across the organisation by the end of July 2019 which
also confirms the guidance, policy and practice to be adhered to when treating patients with dual
diagnosis. Referral processes from acute care to alcohol and substance misuse providers have now
been formalised and the Trust is now formally referring patients to these providers rather than relying
on self referral by service users.
A review of the protocol for communicating crisis calls to all teams involved in care delivery to
2.
ensure a robust system of communication has not been acted upon. I heard evidence that prior to
Nora’s death there had been two separate incidents which led to significant patient harm and/or death
which involved gaps in crisis call communication. Consideration should be given to ensuring this review
takes place and the protocol appropriately modified as a matter of urgency;
We have taken the opportunity to strengthen our internal arrangements for communicating crisis
messages through the development of a dedicated crisis email address within our Home Treatment
Teams. During the hours of Monday to Friday 0900 to 1700 hours, there is dedicated support to
manage this system and to allocate calls. This system has been evaluated positively and is now being
rolled out to our Community Mental Health Teams.
We have also increased the capacity of our out of hours service by putting a senior clinician (Band 7)
on duty each evening from 4pm – 2am to manage and triage activity across our Home Treatment
Teams. They take calls as well as assess if additional support is required. Alongside this we have re-
organised how calls are taken by administrative staff and handed over with a signature to qualified staff
to action.
I heard evidence that the Home Treatment Team model was undergoing a process of review
3.
and overhaul, and that this process had taken approximately 18 months to date but there was no
estimate of when this would be completed by. Consideration should therefore be given as to ensuring
that this review is concluded as a matter of urgency and any changes to the Home Treatment Team
model are implemented with similar urgency.
I am pleased to advise you that since this inquest, we have increased the capacity of our Home
Treatment Teams and are now ‘over-recruited’ to medical positions (3 instead of 2). We have also
increased the nursing resource. We are currently recruiting to new team manager posts and
psychology posts to help strengthen the capacity and skill of the team further.
Upon closing this letter, may I please express my thanks to you again for sharing your concerns with
the Trust.
Yours Sincerely
Chief Executive Officer
Birmingham and Solihull
Mental Health NHS Foundation Trust
2
See every Prevention of Future Deaths report matching Birmingham and Solihull Mental Health NHS Foundation 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.