Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0134A, written 15 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 | 15 Apr 2019 |
|---|---|
| Reference | 2019-0134A |
| Deceased | Nyall Brown |
| Coroner | Jacqueline Lake |
| Coroner area | Norfolk |
| Category | Mental Health related deaths · 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 SBE 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 29/05/2018 | commenced an investigation into the death of Nyall Cye BROWN aged 19. The investigation concluded at the end of the inquest on 12/04/2019. The conclusion of the inquest was: Mr Nyall Brown hanged himself. The medical cause of death was: 1a Hypoxic Brain Injury 1b Asphyxia 1c Hanging I! Depression 4 CIRCUMSTANCES OF THE DEATH Mr Brown was taken to hospital following his being found hanging in woodland on 29 January 2018. Mr Brown was discharged from Mental Health Trust care on 8 March 2018. On 17 May 2018 Mr Brown was found hanging in woodland following his sending a text message indicating his whereabouts. Mr Brown was taken to Norfolk and Norwich University Hospital where he died on 22 May 2018. 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. Evidence was heard that Mr Brown’s care records were not reviewed prior to his being seen, which would enable Mr Brown’s full history and risks to be taken into account when assessing him. 2. This is a matter which has been raised with the Trust previously. Staff are expected to read previous records relating to a service user, but this is not always happening. 3. This matter was not considered in the otherwise thorough investigation conducted by the Trust. 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 10 June 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 | [have sent a copy of my report to the Chief Coroner and to the following Interested Persons 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 Dated: 15/04/2019 hate 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 F 5 WN 2019 NHS Foundation Trust Our Ref: JW/ML 0 Trust Management 1% Floor Admin Private and Confidential Hellesdon Hospital Mrs Lake Drayton High Road Senior Coroner for Norfolk Hellesdon Carrow House Norwich 301 King Street NR6 5BE Norwich NR1 2TN 29 May 2019 Dear Mrs Lake Re: Mr Nyall Brown | write in response to your prevention of future deaths report dated 15 April 2019 following the conclusion of the inquest into the death of Mr Nyall Brown. | know you will share a copy of this response with Nyall's family and | would like to express my condolences for their loss. Nyall’s death is a tragedy and it is essential the Trust takes all opportunity to learn. The report recognised the investigation completed by the Trust and its identification of a number of areas of learning. It highlighted a further opportunity for learning following evidence received at the inquest, specifically that Nyall’s care records were not reviewed prior to an appointment with him. The importance of having as much information as possible is critical to informing clinical judgement and outcomes during an appointment. The Trust has commissioned a learning session to be delivered by the Head of Patient Safety and Safeguarding and the Legal Services Manager commencing in June 2019. Alongside a focus on the regulatory, legal and professional responsibilities each clinician holds with respect to record keeping and communication, the session will include content related to the importance of preparation ahead of appointments. To positively influence the Trust's improvement work we are strengthening the clinical and service leadership in order to ensure there is 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 has recruited to the majority of these roles which will be fully effective from September 2019. A key function of this new approach will be the accountability to share learning, implement and monitor recommendations from serious incidents. 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. Yours sincerely Jonathan Warren Chief Executive =@, . 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.nsit.nhs.uk
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