Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0090A, written 18 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 | 18 Mar 2019 |
|---|---|
| Reference | 2019-0090A |
| Deceased | Ellie Long |
| Coroner | Jacqueline Lake |
| Coroner area | Norfolk |
| Category | Child Death (from 2015) · Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Norfolk and Suffolk NHS Foundation Trust |
| 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 Drayton High Road Hellesdon Norwich NR6 5BE 1 CORONER | am Jacqueline LAKE, Senior Coroner for the area of Norfolk 2 CORONER'S LEGAL POWERS | 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 13/12/2017 | commenced an investigation into the death of Ellie Jane LONG, aged 15. The investigation concluded at the end of the inquest on 16/01/2019. The conclusion of the inquest was: Ellie Long took action to end her own life. The evidence does not reveal whether she intended to die. The medical cause of death was: la Hypoxic Brain Injury ib Cardiac Arrest 1c Hanging iT] Anorexia, Depression 4 CIRCUMSTANCES OF THE DEATH Ellie Long was receiving treatment in the community from the Eating Disorder Service. She was diagnosed with Anorexia Nervosa and Depression. On the morning of 10 December 2017, Miss Long went to her bedroom, where she was found hanging later that morning. Emergency Services were called, and Miss Long was taken to Norfolk and Norwich University Hospital where she died on 12 December 2017. 5 CORONER’S CONCERNS During the course of the inquest, the evidence revealed matters giving rise to concern. These were dealt with by way of written representations submitted on behalf of IPs. Some of the concerns raised have been dealt with and | propose taking no further action. However, as indicated in Court today, 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. Record keeping and Auditing of Record keeping a) Not all records were properly recorded on Lorenzo. Further, personal handwritten notes were made of some meetings which were not then reflected in the electronic records. Some of these notes only came to light during the inquest hearing. It is, of course, imperative that all staff recognise their obligations in respect of keeping full and contemporaneous electronic records and that full disclosure of all relevant documents is made in a timely fashion before the inquest commences. This avoids potential delay in the inquest process and further distress to the family. b} Some action has been taken by NSFT in this respect, not least in that the team is now better resourced staff-wise. Further action has been and is being taken to ensure staff appreciate the importance of full record keeping. An audit of the records has been undertaken to ensure full compliance with record keeping requirements but this will only continue until 100% compliance has been achieved. c) Concern remains in that staff do change over time and matters raised now do not necessarily remain at the forefront of an individual’s mind, especially when under time pressure. Good record keeping is an integral part of any good service and must be second nature to all staff. It must be fully appreciated by all as “a vital component in the management of risk’. Further, record keeping has been raised elsewhere as a matter of concern within NSFT. d) | have concern that full record keeping and disclosure requirements will not remain a priority. 2. Communication with External Agencies a) An initial full, updating letter was sent to Ellie’s GP. However no further updating information was sent. A letter was written providing updating information, but this was not sent. No further updating information was sent to the GP by telephone, letter or email. b) The evidence heard is that efforts were made to contact the school by telephone. However, the school had no record of any such calls. There is no evidence of email or written correspondence or further telephone calls in an effort to communicate with the school. c) Itis accepted by the Trust that sharing of relevant information is necessary. NSFT has indicated it will “remind staff of the importance of recording efforts to share information/maintain communication”. d) Sharing of information and communication with external agencies is a matter which has been raised with NSFT on previous occasions. The importance of “recording efforts to share information ...” may not be sufficient to prevent future deaths. It is the importance of sharing information and communicating with external agencies that should be addressed here. Recording of information is dealt with at Point 1 above. 6 ACTION SHOULD BE TAKEN tn 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 13 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. 8 COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the following interested Persons: a i} | have also sent it to Norwich Ctinical Commissioning Group Norfolk Child Death Overview Panel, Norfolk County Council Norfolk Local Safeguarding Board Educational Psychology: Specialist Support, Children’s Services Department Norfolk Constabulary Legal Services | Wymondham Medical Practice who may find it useful or of interest. 1am 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: 18/03/2019 lke. 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 Our Ref: JW/ML Trust Management 1 Floor Admin Private and Confidential 2 2 Hellesdon Hospital Mrs Lake MAY 2019 Drayton High Road Senior Coroner for Norfolk Hellesdon Carrow House Norwich 301 King Street NR6 5BE Norwich NR1 2TN 17 May 2019 Dear Mrs Lake Re: Ms Ellie Long | write in response to your prevention of future deaths report dated 18 March 2019 following the conclusion of the inquest into the death of Ms Ellie Long. | know you will share a copy of this response with Ellie’s family and | would like to express my condolences for their loss. Ellie’s death is a tragedy and it is essential the Trust takes all opportunity to learn. The report raised concern in two areas. Record keeping The report detailed that not all records were entered on to the Trust's electronic health record system. Further, some meeting notes recorded by hand were not subsequently reflected within the record. The inquest heard evidence of the actions the team have taken to improve this area, using audit as a means to provide confirmation and assurance. Communication with external agencies The report noted the importance of recording the attempts at contact with partner agencies, but highlighted it is the actual contact being made that is the critical action. It is positive to note that the team have taken action in response to this learning. However, it is foreseeable that the aspect of record keeping and communication could be present in any team. The Trust is taking the following actions which are anticipated to assist in bringing consistent and sustained improvement. All clinical services have been instructed to review their working practice in respect of record keeping and communication with partner agencies. Responsibility for this rests with the operational managers who will provide assurance of the actions taken to drive improvement. Supporting this is a learning session to be delivered by the Head of Patient Safety and Safeguarding and the Legal Services Manager. The session will have a specific focus on the regulatory, legal and professional responsibilities each clinician holds with respect to record keeping and communication. The Trust is strengthening its clinical and service leadership to ensure they have the necessary breadth of skills and resource to lead safe and effective services. Of particular note, the Trust will be introducing Patient Participation Leads for each locality, who will work alongside new Clinical Directors to lead the components of quality and patient experience. The Trust is finalising the recruitment to these roles which will be fully effective from September 2019. A key function of this new approach will be the 0, i} Chair: Marie Gabriel CBE Chief Executive: Jonathan Warren x ee 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 accountability to share learning, implement and monitor recommendations from serious incidents. Their role is to support the local clinical services function effectively, working alongside their network of partner agencies. The Trust will gain assurance these interventions are working through a number of indicators. This will include audit, user feedback and the outcomes of quality and safety reviews. To support an effective assurance system, the Trust is implementing a new governance structure enabling a combined and tiered approach that will provide the culture and conditions for improvement. Thank you for providing this report to the Trust. These are important matters which require diligent attention at all levels of the Trust in order to provide safe and effective care. Yours sincerely Jonathan Warren Chief Executive
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