Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0122, 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 | 2019-0122 |
| Deceased | Mohammed Hussain |
| Coroner | Emma Whitting |
| Coroner area | Bedfordshire & Luton |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | East London 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 THIS REPORT IS BEING SENT TO: Dr Navina Evans, Chief Executive, East London Foundation NHS Trust, Robert Dolan House, Trust Headquarters, 9 Alie St, London E1 8DE CORONER lam Emma Whitting, Senior Coroner for Bedfordshire & Luton 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. http//www_legislation.gov.uk/uksi/2013/1629/part/7/made INVESTIGATION and INQUEST On 15 May 2018 the Acting Senior Coroner for Bedfordshire & Luton commenced an investigation was into the death of Mr Mohammed Hussain, aged 30. The investigation concluded at the end of the Inquest held by me on 26 February 2019 and on 7 March 2019 my determinations and conclusion were delivered. The medical cause of death was found to be: 1a Carbon Monoxide Toxicity and Extensive Burns The Conclusion of the Inquest was a Narrative Conclusion: The Deceased took his own life, intending to do so, but whilst suffering from mental distress a CIRCUMSTANCES OF THE DEATH The Deceased suffered a deterioration in his mental health from November 2017. On 21 December 2017, he was admitted to the Luton & Dunstable hospital following an overdose and was assessed by psychiatric services who referred him for GP review. On 28 April 2018, he took a further overdose and, on 30 April 2018, was assessed by his GP as being at high risk of suicide and was re-referred to psychiatric services. Although he was still at high risk, psychiatric services initially assessed him to be at medium risk and he was discharged for a community assessment at home the following day when his risk level was further reduced to low; apart from counselling services and medication, he was not offered any further psychiatric support. As his condition continued to deteriorate, alternative medical management may have altered subsequent events. On 12 March 2018, he drove himself to Eldon Rd, Luton, where he parked and, shortly before 18.00 hours, having soaked the interior of the car with fuel, he set fire to himself whilst sitting in the rear passenger seat. His death was confirmed by police who attended the scene at 19.00 hours. 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 could 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 Trust had carried out a Serious Incident Investigation (Sil) into the circumstances of the Mr Hussain’s death which was critical of both the mental health assessments of Mr Hussain carried out by staff on 30 April and 1 May 2018. This meant that 3 individual staff members had misunderstood or misapplied their risk assessment training. (2) 1 was informed by the Trust that further risk assessment training was carried out by the Trust following Mr Hussain’s death and yet, at the Inquest, both members of staff (although, one has now moved to another Trust) showed little insight into their actions despite the Sil ‘s findings and the further training. (3) It was also apparent at the Inquest that important information required for the risk assessment process had not necessarily been passed and/or sufficiently highlighted in communications both between individual Trust staff members and with other care providers ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you have the power to take such action. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 8 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. COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to Mr Hussain’s family. 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. 13 March 2019 SIGNED BY HM SENIOR CORONER: Ao nwslet
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.
East London NHS Foundation Trust Please respond to: Associate Director of Legal Affairs Trust Headquarters 9 Alie Street London E1 8DE Telephone: 0207 655 4064 14" June 2017 Senior Coroner Ms Emma Whitting The Court House Woburn Street Ampthill Bedfordshire MK45 2HX Dear Madam Inquest touching upon the death of Mohammed Hussain This is a formal response to your Regulations 28 Report dated 13th March 2019 in which you set out your concerns relating to the care Mr Hussain received from East London NHS Foundation Trust. Your concerns related to the assessment of risk by staff in our Bedford crisis services on both 30 April and 1 May 2018. As you have noted this was identified in the Trust's Serious Incident Review Report. | am aware that you heard evidence during the course of the Inquest that the Trust has mandatory training in Clinical Risk Assessment in place and that as a result of the concerns highlighted in the Serious Incident Review additional risk assessment training had been put into place and would continue to be delivered on an ongoing basis. However, having heard the evidence of staff, you were concerned that they had potentially misunderstood or misapplied both the mandatory and additional risk assessment training. The importance of good quality, appropriate risk assessment is a key skill for all our Clinical staff and the Trust is looking at several ways to support staff with this. Within the crisis services in Bedfordshire further training has now been organised and is currently being delivered to staff specifically looking at assessment of risk and suicide prevention. Chair Chief Executive: Dr Navina Evans In addition we have recently appointed to a new role of Clinical Director for Crisis Pathway and Liaison and the postholder will be reviewing the whole crisis pathway to identify and implement improvements. Given the importance of this issue | am also looking at this on a Trust wide basis and have been working with external experts with a view to developing a new risk assessment tool to roll out across the Trust. | acknowledge that this work may take some time to refine and implement. In the meantime a Suicide Prevention Awareness Day has been organised for July and our suicide prevention training is currently being reviewed and refreshed for implementation across our services. | hope that the information above reassures you that the Trust has taken your concerns seriously and that the action taken has adequately addressed those concerns. If you do require any further information please do not hesitate to contact me. Yours faithfully Chief Medical Officer Chair: Marie Gabriel Chief Executive: Dr Navina Evans
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