Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0125A, written 2 Apr 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 2 Apr 2019 |
|---|---|
| Reference | 2019-0125A |
| Deceased | Stuart Clark |
| Coroner | Philip Spinney |
| Coroner area | Exeter and Greater Devon |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths · Suicide (from 2015) |
| 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 FUTURE DEATHS THIS REPORT DATED 3 APRIL 2019 IS BEING SENT TO: 4. Ms Suzanne Tracey, Chief Executive of Royal Devon and Exeter NHS Foundation Trust 1 | CORONER | am Philip Charles SPINNEY, HM Senior Coroner, for the Coroner area of Exeter and Greater Devon. 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 3 October 2017 an investigation was commenced into the death of Stuart Michael CLARK. The investigation concluded at the end of the inquest held on 2 April 2019. The conclusion of the inquest was as follows: Suicide 4 | CIRCUMSTANCES OF THE DEATH Stuart Michael CLARK had a long history of suffering with his mental health. On 3 October 2017 he jumped into the canal at Haven Road, Exeter wearing a rucksack filled with weights. He was recovered from the water and taken to the Royal Devon and Exeter Hospital where he sadly died shortly after arriving. More specifically, Mr CLARK had a history of Asperger's Syndrome, Dyspraxia, Developmental Dyslexia and Irlen’s Syndrome. In the weeks before he died he complained of a rash, pain and swelling believed to be an allergic reaction. On 30 September 2017 he was admitted to the Royal Devon and Exeter Hospital due to pain, swelling and a history of diarrhoea and nausea; on assessment he was extremely anxious and concerned about his physical illness. During his admission he disclosed to a nurse on the ward that he was a vulnerable adult and a suicide risk. This information was not escalated, and no assessment was made to determine his risk of self-harm and suicide. 5 | CORONER’S CONCERNS During the course of the Inquest the evidence revealed matters giving rise to concer. 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 evidence revealed that Mr CLARK disclosed to a member of nursing staff on Lowman (Capener) Ward at the Royal Devon and Exeter Hospital that he was a vulnerable adult and a suicide risk. This disclosure was not followed up with an assessment to determine if Mr CLARK had any intent, plan or history of self-harm or suicide. An assessment would have helped determine his risk and inform the decision on a referral to mental health services. Senior Clinical staff were not directly informed of the disclosure. The SHO Dr responsible for Mr CLARK stated in her evidence that had she known about the disclosure she would have assessed his risk of self-harm and suicide, and if appropriate she would have referred him to the mental health services. The nurse made an entry in the medical records; however, the medical notes were not made up until the end of the day and therefore the information was not available to other staff at the relevant time. ACTION SHOULD BE TAKEN (1) Consideration should be given to reviewing procedures and training related to the actions to be taken when a disclosure is made to ward staff giving rise to a suspicion of the risk of self-harm or suicide. In my opinion action should be taken to prevent future deaths and | believe you and your organisation 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 29 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 family of Stuart Michael CLARK. | am also under a duty to send the Chief Coroner a copy of your response. publish either or both in a complete or redacted or summary py of this report to any person who he believes may find it useful fy make representations to me, the coroner, at the time of your rAlease or the publication of your response by the Chief Coroner. Mr Philip C Spinney HM Senior Coroner
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 Philip Spinney Senior Coroner for Exeter & Greater Devon Exeter Coroners Office County Hall Topsham Road Exeter EX2 4QD Our Ref: ST/LV 28 May 2019 Dear Mr Spinney Royal Devon and Exeter Hospital (Wonford) Barrack Road Exeter EX2 5DW Tel: 01392 411611 CHIEF EXECUTIVE’S OFFICE Direct Dial: Email: Re Stuart Michael Clark (Died: 03/10/2017) I am writing further to your letter dated 5 April 2019, enclosing your Regulation 28 Report to Prevent Future Deaths. “review procedures and training related to the actions to be taken when a disclosure is made to ward staff giving rise to the suspicion of the risk of self-harm or suicide”. In response to this, the Royal Devon and Exeter NHS Foundation Trust (The Trust) has reviewed its current training and support available to ward staff in relation to: Recognising a person at risk (Vulnerable adult); Responding to, and escalating concerns; and Safeguarding Adults There is a mandatory training programme that is completed by all staff on induction with the Trust, whatever their role. Regular updates are required at a maximum interval of every three years. The training programme has the following objectives: Raise awareness of safeguarding issues Be aware of signs and symptoms of abuse Understand own responsibilities to safeguard Understand Prevent issues: Recognising when vulnerable people are at risk of / have been radicalised Increase knowledge of MCA and DoLS Have knowledge of relevant procedures Know where to access support and further information. All staff are informed at induction and in training that they are responsible for escalating concerns about safeguarding or other risks to patients. Ward staff are taught about self-neglect as part of safeguarding training. Sometimes this reaches a threshold of safeguarding referral in accordance with the Care Act. The Trust Safeguarding team is available weekdays 8.30am – 5pm to give advice to staff about any safeguarding matter. We empower staff to safeguard patients themselves, but the Safeguarding Team do also see some more complex cases themselves or with staff. This is supported by the Trust’s Safeguarding Adults Policy, monthly Safeguarding newsletters and regularly updated information on the Trust’s intranet service “Hub”, all of these are accessible to all employees. The Hub information includes a multi-agency leaflet ‘It’s safe to talk about suicide’. The Safer Devon Partnership, which is the statutory County Strategy Group, which provides strategic leadership for addressing community safety issues affecting vulnerable people, currently have a group reviewing suicide prevention. We will be reviewing our provision again in light of this review. Specific training has been provided from Devon Partnership Trust for our highest risk areas, AMU and Emergency Department. The Trust has mental health support available 24 hours a day from our liaison psychiatry service provided by Devon Partnership Trust. This is what is currently in place in the Trust to ensure that staff are aware of their duties for safeguarding patients. However, the Trust is always seeking to improve safety for its patients. We will be reinforcing individual responsibility and accountability for patient safety and suicide prevention to all staff. In June 2019, the Trust is running a two day ‘Care Matters’ professional leadership forum for Nurses, Allied Health Professionals and midwives. These sessions will be run and delivered in person by Deputy Chief Executive/Chief Nurse, and will reach over 100 leads who will then cascade to their respective teams. The focus of this forum is Professional Safety and this case will be used during this forum as an example to reiterate the importance of escalating concerns about vulnerable patients to ensure the appropriate assessments and support can be provided to them. The Trust is satisfied that this was an isolated incident and staff are aware of their safeguarding obligations. However, the Safeguarding Team is going to issue a reminder to all staff in an upcoming newsletter (which reaches all clinical staff) about safeguarding procedures when there is a disclosure about possible suicidal intent. This briefing will include information about the ‘It’s safe to talk about suicide’ leaflet, a copy of which is attached. This is available on the Trust’s Safeguarding intranet page but we want to raise awareness further of this issue. The leaflet was produced by Exeter Medical School in conjunction with Suicide Charities and Devon County Council for staff to use to support people when suicidal intention is disclosed. I hope that all of the above provides reassurance that all staff are aware, and will be reminded of, their obligations of what actions to take when faced with vulnerable adults who may be at risk of self- harm. Please do not hesitate to contact me if you require any further information. Yours sincerely Suzanne Tracey CHIEF EXECUTIVE Enc ‘It’s safe to talk about suicide’ leaflet
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