Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0159, written 17 May 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 17 May 2019 |
|---|---|
| Reference | 2019-0159 |
| Deceased | Barry Fullarton |
| Coroner | Andre Rebello |
| Coroner area | Liverpool and Wirral |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Cheshire and Wirral Partnership 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 (1) NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: 1 Cheshire and Wirral Partnership NHS Foundation Trust 1 CORONER I am Andre REBELLO, Senior Coroner for the area of Liverpool and Wirral 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 20/12/2018 I commenced an investigation into the death of Barry Marshall Fullarton aged 79. The investigation concluded at the end of the inquest on 17 May 2019. The conclusion of the inquest was: Barry Marshall Fullerton died by Suicide, when suffering from a reactive depressive illness, which affected his mood in the morning. The Cause of death was: I a Multiple injuries I b--------------------- I c -------------------- II --------------------- 4 CIRCUMSTANCES OF THE DEATH On the 17th December 2018 at 9.05 Barry Marshall Fullerton was certified as having died beneath the balcony of his bedroom at placed on the balcony above. It is found that he used this intentionally to fall over the balcony with fatal intent. In October 2018, Mr Fullarton had suffered a stroke which was more likely than not the cause of a reactive depressive illness which included a significant diurnal variation in mood (low mood in the morning and normal affect in the afternoon). The depressive illness manifested in thoughts of intentional self-harm and suicide. On the 14th December 2018, Barry Fullerton underwent a mental health assessment. This took place in an afternoon and he was assessed as being safe to go home. He was on anti-depressant medication (found present in post-mortem toxicology) but he had declined to engage in an assessment of appropriate psychological therapy plan. It is unclear as to whether a mental health assessment in a morning would have assessed different needs. , West Kirkby. There was a chair 5 CORONER’S CONCERNS The MATTERS OF CONCERNS are as follows: Those carrying out mental health assessments should have regard to how a mental disorder manifests in a patient. In this case, the diurnal nature of the reactive depressive illness was evident from the medial records such that an assessor could have documented that the assessment at a particular time when mood was good may not be valid when in low mood. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) 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 12 July 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 Mr Fullarton’s 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 Andre REBELLO Senior Coroner for Liverpool and Wirral Dated: 17 May 2019
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) Cheshire and Wirral Partnership NHS Foundation Trust Trust Headquarters Redesmere Andre Rebello Countess of Chester Health Park Senior Coroner Liverpool Road Liverpool and Wirral Chester HM Coroners Court CH2 1BQ Gerard Majella Courthouse Boundary Street Telephone: 01244 397393 Liverpool L5 22QD Date: 08 July 2019 Dear Mr Rebello Re: Regulation 28 Report, Barry Marshall Fullarton | acknowledge receipt of your Regulation 28, dated 17 May 2019, which was sent following the conclusion of the inquest into the death of Mr Fullarton. You have asked for the Trust’s response to the areas of concern raised within this report, to detail the proposed actions to be taken by the Trust along with the timetable for these actions. The area of concern highlighted in your report is as follows: Those carrying out mental health assessments should have regard to how a mental disorder manifests in a patient. In this case, the diurnal nature of the reactive depressive illness was evident from the medial records such that an assessor could have documented that the assessment at a particular time when mood was good may not be a valid when in low mood. Diurnal mood variation (DMV) is considered a prominent symptom of depression, as such, this is part of the training that our clinicians receive. This training includes the importance of diagnosing depression and gaining an understanding about a person’s sleep patterns and changes in mood over the course of the day. This training helps to assess for and differentiate between the different symptoms of depression. It may not always be possible to offer appointments at different times of the day, however, given the concerns you have shared, we plan to use your helpful feedback as learning. As such, the Trust will provide further guidance to our staff regarding ways that they can consider facilitating appointments at different times of the day, through the following actions: e We will develop a share learning bulletin to outline the importance of responding to assessments for DMV, and include the consideration as to whether people should and could be seen at different times. This will be circulated to all our clinical teams by the end of July 2019. This will be sent directly to all staff, and will also be included in governance and team meetings. e There is a Trustwide Grand Round for all clinicians in September 2019, where this learning and feedback will be shared. Helping people to be the best they can be We produce a Trustwide Learning from Experience report three times a year, in which we plan to summarise this learning as part of that report, confirm the above actions, and follow-up their completion. The next edition, which covers the time period April — July 2019, will be presented at our Trustwide Quality Committee in September 2019. This will ensure oversight of the delivery of the actions we have stated above. e The Suicide Prevention Training will also be adapted to include DMV when teaching around depression and Mental State Examination. | would like to assure you that as a Trust, we have taken the matters outlined within your report extremely seriously, and that we remain committed to ensuring that we continuously review and learn to help us to improve the care that we provide to people accessing our services. Yours sincerely Sheena Cumiskey Chief Executive Helping people to be the best they can be
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