Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0186, written 24 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 | 24 May 2019 |
|---|---|
| Reference | 2019-0186 |
| Deceased | Noah Lomax |
| Coroner | Angharad Davies |
| Coroner area | South Yorkshire (West) |
| Category | Child Death (from 2015) · Hospital Death (Clinical Procedures and medical management) related deaths |
| 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 THIS REPORT IS BEING SENT TO: 1. Chief Executive, Sheffield Children’s NHS Foundation Trust Copied for interest to: 2. Noah Lomax’s family. 3. The Crookes GP Practice, Sheffield. 1 CORONER I am Angharad Davies, assistant coroner, for the coroner area of South Yorkshire, West. 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 An investigation was commenced into Noah Lomax’s death on 8 August 2018 and an Inquest was opened the same day. I concluded an inquest on 24 May 2015. The findings of the court were as follows: Medical Cause of death 1(a) Multiple Injuries Conclusion: Suicide 4 CIRCUMSTANCES OF THE DEATH Noah was 15 years of age. At the beginning of July 2018 Noah’s mother was made aware of online communication between Noah and a friend in which he expressed an intention to take his own life by jumping off a bridge. Noah’s mother acted immediately upon this concern and both made an appointment for Noah to see his GP and to attend Door43 an organisation that provides emotional support for young people. Noah’s and his mother attended the GP appointment with the specific intention to obtain help by way of a referral to CAMHS. Noah’s GP was told that he had suicidal thoughts and had plans to take his own life. Noah’s GP completed a written, non-urgent, referral to CAMHS CAMHS processed the referral promptly but the referral contained insufficient information for a risk assessment to be performed Therefore, CAMHS closed Noah’s referral but invited his GP to provide further information. Noah’s GP planned to use the appointment arranged on 6 August 2018 as an opportunity to obtain the further information sought by CAMHS. Noah’s family were not notified that CAMHS had declined the referral. The Trust accepted that the process of requesting further information was not sufficiently robust and that telephone contact with the GP should have been made. This would have avoided the need for a re-referral. Had the information been known that Noah was actively making plans to take his own life CAMHS would have categorised his appointment as urgent and seen him within 2 weeks. Assumptions were made regarding the support being offered to Noah by Door43. The Trust accepted that the actual level of support ought to have been confirmed directly between CAMHS and Door43. The Trust accepted that the current referral form does not capture the information required to process referrals without delay. Noah went on holiday with his father and step-mother between 22 July and 29 July 2018. Noah was not seen by CAMHS on his return. On 1 August 2018 Noah was not open with his mother about his plans. Instead of spending the day with friends he travelled, by a pre-planned route, to Conisborough Viaduct. Sometime after 1.30pm Noah took his own life by jumping from the Viaduct. 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 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. As I made clear during the Inquest I was concerned about the adequacy of the CAMHS, GP referral form. , Noah’s GP, was inexperienced she had not completed a CAMHS referral form before. She accepted that she had not provided sufficient detail in the form. This resulted in CAMHS being unable to assess Noah’s risk and declining Noah’s referral. This in turn meant that Noah did not receive an appointment with CAMHS before his death. The Trust’s investigation report stated that the evidence “suggests that the current referral form does not capture the information required to process referrals without delay.” , CAMHS Clinical Lead, said that there had not been any other problems with the form with GP’s not completing them sufficiently. I am not is able to be so confident about this. sure how I was told that redesigning the form had been considered by the Trust but was told that this was not the answer. Instead, further training has been provided to GPs within the area. Guidance is attached to the form to assist GPs in completing the form. Having carefully considered the evidence I am not satisfied that steps have been put in place to ameliorate the risk identified. Given the realities of the pressures on a GP’s day expecting a GP to use their 10 minute appointment to extract sufficient information for the referral and then at some point complete a referral form, with which they may be unfamiliar, creates the risk that relevant information may not be provided. I would invite the Trust to reconsider whether the form could be improved to reduce the risk of inadequate or insufficient information being provided which may result in a delay in care. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you 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 19 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 Noah Lomax’s Family, GP, Sheffield Children’s Hospital NHS Foundation Trust. 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 24 May 2019 Angharad Davies Assistant Coroner South Yorkshire (West)
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.
Your ref: REG 28 LOMAX Our ref: MW/R28NLOMAX Ms A Davies Assistant Coroner Medico-Legal Centre Watery Street Sheffield Sheffield Children’s [E53 NHS Foundation Trust "RECEIVED 06 JUL 2019 HLM. wees Western Bank Sheffield S10 2TH www. sheffieldchildrens.nhs uk $3 7ES 27 June 2019 _—CT— Dear Ms Davies Noah Lomax (deceased) Regulation 28 | write in response to your Regulation 28 Report to Prevent Future Deaths dated 24 May 2019. Under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 you requested the Trust to consider your matter for concern and take action to prevent future deaths. The Trust sets out below its response to your matter of concern below: During the inquest into the death of Noah Lomax you expressed concerns about the adequacy of the CAMHS referral form that is used by General Practitioners. You identified that our investigation report stated that the evidence ‘suggests that the current referral form does not capture the information required to process referrals without delay’ and that during the inquest you heard evidence that there had not been any other problems with GP’s not completing them sufficiently and that redesigning the form had been considered by the Trust but was told this was not the answer. You were informed further training had been provided to General Practitioners and guidance had been attached to the referral forms to assist General Practitioners with this process. The actions described above did not assure you that satisfactory steps have been put in place to ameliorate the risk identified. You have therefore invited our Trust to reconsider whether the form could be improved to reduce the risk of inadequate or insufficient information being provided, which may result in a delay in care. During the inquest it was confirmed that the referral guidelines were being updated with input from a General Practitioner. This has now been completed and the guidance is now in place and being used. The current form will continue to be used alongside the new guidance in mitigation until the actions outlined below have been completed. The CAMHS team have commenced a review of the referral form, and a draft form was sent to the Clinical Director for Mental Health commissioning the Sheffield Clinical Commissioning Group (SCCG), for comments. This draft was reviewed by SCCG’s Clinical Reference Group, which \ Sheffield Ais Children’s ye prer John Somers S \/ S Volinteer [x “¥ Sarah Jones Chief Executive Standard “Osage ent y 4 Chair 19517, consists of a number of General Practitioners and 2 service users. Comments from this group have been collated and are to inform necessary amendments to the referral form. Subsequently the current guidance will be updated to support the new referral form and this will then be distributed to all General Practitioners. The form and guidance are currently being reviewed and updated and will be distributed to all General Practitioners by 12 July 2019. If | can be of any further assistance please do not hesitate to contact me. Yours sincerel John Somers Sheffield Children’s NHS Foundation Trust wat Mog The sett " s ap nether John Somers SVS ratte sYSs Children’s = Sarah Jones Chief Executive Standard “Otay Hospital My Chair
See every Prevention of Future Deaths report matching Child Death (from 2015), and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.