Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0259, written 29 Jul 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 29 Jul 2019 |
|---|---|
| Reference | 2019-0259 |
| Deceased | Alex Blake |
| Coroner | Andrew Harris |
| Coroner area | London Inner (South) |
| Category | Alcohol, drug and medication related deaths · Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
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. 1st Floor, 1 Kemble Street, London WC2B 4AN , Chair of Fitness to Practice, Nursing and Midwifery Council, 2. Mr Neil Lloyd CEO, NHS Professionals Ltd, Suites 1A & 1B, Breakspear Park, Breakspear Way, Hemel Hempstead, HP2 4TZ 1 CORONER I am Andrew Harris, Senior Coroner, London Inner South jurisdiction 2 CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. 3 INQUEST I opened an inquest into the death of Mr Alex Blake, who died on 24th June 2018 in Lambeth Hospital (01761-2018). An investigation and inquest was opened on 29th June 2018 and was concluded on 27th June 2019. A jury was summoned. The medical cause of death was: 1a Heroin Toxicity 4 CIRCUMSTANCES OF THE DEATH The jury concluded that he died from a self-administered heroin overdose whilst a sectioned in-patient under the care of South London & Maudsley Trust at Lambeth Hospital, sometime before 04.13 on 24.06.18. The jury concluded that there were inadequate observations conducted on the night, which meant that his death went unnoticed for several hours, due to unsuitable record sheets, ineffective observations and lack of communication between staff. There was evidence that rigor mortis had begun when he was found, based on evidence of the attending paramedic. 5 CORONER’S CONCERNS During the course of the inquest, the evidence revealed concerns with the implications of the evidence of three witnesses employed by NHS Professionals at times when the deceased was already dead. This leads me to have an opinion that there is still a risk that future deaths will occur unless action is taken with respect to these individuals. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. – The first was RMN T, who gave evidence that the deceased was half out of bed, wearing pyjamas and she assumed to be asleep at 05.00. When asked whether he could have been dead, the nurse said she did not know, but it was too dark to see and no torch was used. She chose to wait until 06.00 to conduct a proper observation. She could not answer the question why she had not gone to get a torch or returned before 06.00. When found in the same position an hour later, she says she was concerned and asked Health Care assistant K if he was breathing as he had been in the same position for an hour. HCA K denies that this conversation took place before he was found dead. RMN T on finding the deceased said that it still did not occur to her that he might be dead. Her evidence to the court that he was wearing pyjamas at 05.00 is in contrast to the electronic patient journal, which confirms that when he was found dead he was topless. The second was RMN E, whose evidence was read due to his unavailability. He made an entry in the electronic journal at 05.59, which is about the time which he was found dead, that “he went to his bedroom and was observed asleep from 23.00 hrs. Alex remains asleep and was observed breathing regularly at the time of this entry (05.52).” The deceased was already dead at the time this entry claims to have been written. RMN T told the court that she had no communication with RMN E about his observations and RMN E was not one of those who found him dead at about 06.10 hours. This raises concern about what prompted the unusual entry at 05.59. The third was health care assistant K, whose evidence in court was that the deceased was observed at 03.00 and he held his phone in his hand which was lit up, and so assumed to be watching a film. The witness was unable to answer why he had then recorded the deceased as being asleep, as it would be likely then that the light of the phone would not be visible. The evidence of these three witnesses cannot be said to be reliable. The evidence of the two nurses would seem to go beyond that of poorly conducted observations. It would be reasonable to suspect that that either the two nurses did not perform the observations at all or that they have provided false evidence to the Trust and to the court. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths. I believe that the following organizations would wish to learn of the circumstances of this death and are in a position to mitigate or prevent future deaths: As all three are employees of NHS Professionals, the agency is informed of this evidence so that they might consider whether to conduct an internal investigation or fitness to practice investigations and additionally consider whether there are wider implications for their recruitment and training processes. Given the serious professional and legal implications of the evidence of the nurses each is referred to the Nursing & Midwifery Council. Their identities are communicated separately and confidentially. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by Wednesday 25th September 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. If you require any further information or assistance about the case, please contact the case officer, 8 COPIES and PUBLICATION I have sent a copy of my report to the following Interested Persons: , Mother Dr Matthew Patrick Chief Executive, SLAM I am also sending this report to the following, who may have an interest, Secretary of State for Health, NHS England and Royal College of Psychiatrists. 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 [DATE] [SIGNED BY CORONER] 29th July 2019 Andrew Harris, Senior Coroner
2 responses 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.
From the Chief Executive and Registrar Nursing & Midwifery Council Andrew Harris HM Senior Coroner Coroner for Inner South District Greater London Southwark Coroner's Court 1 Tennis Street 8 Southwark SE1 1YD 13 September 2019 Dear Sir Re: The Late Alex James Blake — Regulation 28 prevention of Future Deaths Report Further to your report to Prevent Future Deaths made under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013, | am writing to provide you with the Nursing and Midwifery Council's ((NMC’s’) response. Firstly, | would like to offer my sincere condolences to Mr Blake’s family for their loss, and to assure you and them that | take the concerns you have raised very seriously. Action we are taking in this case | note that the concerns are focused on three named individuals, two of whom are registered nurses, and one of whom is a healthcare assistant (HCA). | have passed your report regarding the two registered nurses to our Fitness to Practise team for further investigation; we have now also received a formal referral from NHS Professionals in respect of these two nurses. The case of the two nurses is now with our screening team and they will use the information we have received from your office and NHS Professionais to consider the matter further. | would be happy to arrange for you to receive further updates about the progress of the case if that would be helpful Our Employer Link Service (ELS) has been in touch with the trust and NHS Professionals to try to understand the delays that occurred in referring these nurses to us and to learn for the future. The ELS will also be following up with the trust and NHS Professionals to ensure that there are processes in place to ensure that prompt referrals are made in appropriate cases in the future. 23 Portland Place, London W1B 1PZ T 020 7637 7181 www.nmec.org.uk We are the professional regulatory bady for nurses and midwives in the UK. Our role is to protect patients and the public through efficient and effective regulation. Registered charity in England and Wales (1091434) and in Scotland (SC038362) Page 1 of 2 With regard to the HCA mentioned in your letter, we are unable to direct action against this individual. Our statutory remit covers nurses, midwives and nursing associates effective on our register. However, we have referred your concerns about this individual to the Care Quality Commission, who will be able to take any action or make any recommendations they consider to be appropriate in relation to the trust's use of agency staff. | hope that my letter reassures you that we are taking all appropriate action to address your concerns. If you have any further questions regarding this case or the action we have taken, please do not hesitate to get in touch. | would also like to reassure you and Mr Blake’s family that it is open to them to speak to our Public Support Service for information and support concerning our fitness to practise processes. | will ask my colleagues in that team to contact them about the support they can provide. Finally, please can you ensure that any future Regulation 28 prevention of Future Deaths Reports are sent to me at 23 Portland Place, London, W1B 1PZ as this will enable us to deal with any future reports as promptly as possible. Thank you again for writing to me. Yours sincerely Andrea Sutcliffe CBE Chief Executive and Registrar Page 2 of 2 Ip
Our ref: CIMS 73695, 73696 and 73697 Case ref: 01761-2018 NHS Professionals Ltd Private and Confidential Suites 1A & 1B preakspear walk . reakspear Wa a Andrew Harris Hemel Hempstead enior Coroner Hertfordshire Southwark Coroner's Court HP2 4TZ 1 Tennis Street Southwark SE1 1YD one 20 September 2019 Dear Mr Harris Regulation 28 Report to Prevent Future Deaths following the inquest of Alex James Blake who died at Lambeth Hospital, London, on 24 June 2018 (Case Ref: 01761-2018) I am writing to you to respond to the concerns raised by your investigation into the circumstances surrounding the tragic death of Alex James Blake. NHS Professionals takes very seriously its responsibility to act upon what it learns from unexpected a deaths of patients; who were cared for by Bank Members whilst irr the care of the NHS. In your report you identified the following Matters of Concern: 1. The evidence of the three NHS Professionals Bank Members gave rise to concerns that the mandated observations were either not performed to the requisite standard or not performed at all; and 2. There was inconsistency of account given by the three Bank Members as between their written statements, the records and their oral evidence, raising the possibility of dishonesty. You asked NHS Professionals to consider whether there are wider implications for the organisation’s recruitment and training processes. Your report was sent to two organisations: e NHS Professionals Ltd, Suites 1A &1B, Breakspear Park, Breakspear Way, Hemel Hempstead, HP2 4TZ. ¢ The Nursing & Midwifery Council, 1 Kemble Street, London, WC2 4AN. NHS Professionals is wholly owned by the Department of Health and is the leading provider of a managed flexible workforce into the NHS. NHS Professionals is not a provider of services and provides Bank Members to NHS organisations only. We recruit Bank Members in line with NHS employment check standards and adhere to strict Clinical Governance guidelines when recruiting, training and managing Bank Members. NHS Professionals has been working in partnership with South London & Maudsley NHS Foundation Trust since 2008, providing general and specialist nurses and healthcare workers. Registered ir: England & Wales no. 6704644 Registered Office: NHS Professionals Ltd, Suites 1 8, 1B Breakspear Park, Breakspear Way, Hemel Hempstead HE2 4TZ Professionals Explanation of NHS Professionals role in the provision of flexible staffing in order to respond to the matters raised in your report, it is helpful to set out the ways in which NHS Professionals recruits and retains staff, and the arrangements upon which those staff are assigned to work in NHS organisations. We are committed to providing safe and reliable Bank Members to Client Trusts by working in partnership to support the effective delivery of patient care to the population served by the Trusts we work with. There is a framework for governance and assurance within NHS Professionals supported by the Chief Nurse who is the Director of Clinical Governance and represents clinical leadership on the Board, and the Medical Director who is also the Responsible Officer. Clinical Leadership is overseen by the Clinical Governance Committee, chaired by aclinical Non-Executive Director and is a sub-committee of the NHS Professionals Board. NHS Professionals works in partnership with NHS Trusts to manage temporary staffing banks on their behalf. We currently manage the temporary staff banks for 10 Mental Health Trusts and 45 Acute Trusts, We have approximately 35,000 Bank Members actively working at any one time. Staff working NHS Professionals shifts in a Client Trust have been recruited through one of 3 recruitment processes: Substantive Registration Substantive Registration is the primary registration route, which is available to applicants who hold a substantive post within a Client Trust. The substantive registration process allows substantive staff, referred to as Multi Post Holder Bank Members, to work back at the Trust where they are substantively employed and in an area of work that has been authorised by a Trust Manager. All training requirements for substantive staff are delivered by the Trust. Bank Registration Recruitment Standards The Bank Registration process is available to applicants who do not hold a substantive position in an NHS Professionais Client Trust or where the applicant wants to undertake shifts at a Trust other than where they hold their substantive position. Where this is the case, an applicant will undertake one of two routes toirecruitment: Bank Exclusive: the applicants recruited through this route are known to the Client Trust, Le. have previously worked substantively within the Trust or have worked in the Trust through a commercial agency and are therefore known to the Trust. Following recruitment by NHS Professionals, they will only work in the one Trust in which they are known. Bank Only: the applicants apply to work flexibly across the NHS Professionals client base in the areas where they can demonstrate: e 6 months experience in the previous 2 years e Successful completion of a Knowledge Based Assessment, where applicable linked to grade and speciality. Registered in England & Wales no. 6704614 Registered Office: NHS Professionals Lid, Suites 1A & 1B Breakspear Park, Breakspear Way, Hemet Hempstead HP2 4TZ / " : i Professionals Evaluating Bank Members performance NHS Professionals uses an online performance review and monitoring system that helps to resolve concerns informally at an early stage. It identifies Bank Members who are performing well and also highlights any lack of skills or knowledge development. Performance assessment is completed by the client Trust. NHS Professionals will put in place improvement measures for Bank Members where poor performance or skill deficit has been identified by a Trust. When working an assignment in a Client Trust, NHS Professionals staff work to individual Trust polices and guidelines and this is managed and monitored directly by Trust staff, as opposed to by NHS Professionals. Bank Members are required, along with all Trust staff, to maintain accurate and up to date records and this is monitored and managed directly in the Trust. All registered nurses are bound by The Code (NMC) that is the professional standards of practice and behaviour for nurses, midwives and nursing associates. Under ‘Practise Effectively’ section 10 of The Coda it states, ‘Keep clear and accurate records relevant to your practice’. Action taken by Trust and NHS Professionals following Mr Blake's death NHS Professionals was informed of Mr Blake’s death on 6 July 2018, by the Ward Manager. We were informed that the Bank Members were not implicated in the events surrounding Mr Blake’s death. The manager wanted to ensure that we would be able to support the Bank Members with counselling if required. The Bank Members could continue to work bank shifts within the Trust. We did not receive the SI report. The Trust legal team included the three Bank Members in preparation for the inquest. We were not aware at this time that the shift on 23/24 June 2018 was staffed exclusively by Bank Members. Against the above background, | have set out NHS Professionals’ response below to the matters of concern you have identified and the actions which should be taken. Response to Concerns: As a result of the concerns you have asked NHS Professionals to take the following action: e For NHS Professionals to consider whether to conduct an Internal Investigation or a fitness to practise investigation * For NHS Professionals to consider the wider implications for NHS Professionals recruitment and training For the avoidance of doubt, it is understood that the Coroner has made a referral to the NMC in respect of the staff members concemed. On receipt of the Prevention of Future Deaths Report on 2 August 2019 we obtained all the information relating to the case from South London & Maudsley NHS Foundation Trust which included the Si report. ongoing investigations. | would therefore wish to assure all concerned that action will be taken to remedy any identified organisational or individual deficits arising from this process in the interests of patient safety. | can confirm that the concerns raised were acted upon immediately and are currently the subject of | NHS Professionals Interim Clinical Governance Director and Senior Nurse/ Head of Risk met with the Trust interim Director of Nursing, to review the process undertaken in this case. There are lessons to be learned for NHS Professionals, specifically around the communication between the two organisations and about a systematic approach to information sharing. A future meeting is planned to ensure the Registered in England & Wales no. 8704614 Registered Office: NHS Professionals Ltd, Suites 1A & 4B Breakspear Park, Breakspear Way, Hemel remipstead MPO 472 | appropriate links of the lead Clinicians in both organisations are in place so that ca tegorised and managed Wider Implications for NHS Professionals Recruitment and Training Proc As outlined above NHS Proféssionals recruits to NHS em strict Clinical Governance Professionais' mandatory and statutory training is aligned to the Core Skilis Framework, | provision is reviewed and updated regularly as part o specialist consultant and reviewing all training provisio| i In addition to statutory and mandatory training, individual Client Trusts ma training requirernents for ba NHS Professionals works in partnership with a Client Trust to support delivery of this adc The Trust Engagement and of Competence proforma which requires a competency asses level of observation. This is | Evidencing of successful com | Professionals ¢ cases are accurately effectively and where action is required it is undertaken promptly. | SSCS ployment check standards and adheres to guidelines when recruiting, training and managing Bank members. NHS Training f that process we are currenily working with a n both in practice and ontine, y have specific additional nk|staff who are provided via NHS Professionals and, where this is the case, itional training. Observation Policy Version 6.4 (July 2017) includes a Nursing Verification Sment prior to any ‘nurse’ undertaking any undertaken at ward level. letion and update of the competency assessment was discussed at the meeting with the Interim Director of Nursing and will form part of the actions to be included in the whole systems review. In addition to the above shoulda Client Trust have concerns about by NHS Professionals, they cah inform us about this through the C System (CIMS) feedback form: CIMS is a bespoke complaints ma the competence of a worker provided ompiainis and Incidents Management discussed monthly with Client Trusts, who receive a full report of all ongoing cases to enable them to monitor steps taken. i hope that the information provided offers assurances that the findings of your investigation and the areas of concern you have hi commitment fo providing and Trusts. ; “f ighlighted have prompted action and have been the focus for our continuing improving the provision of safe and effective Bank Members into our Client If you require further information from NHS Professionals in relation to any of the above matter, please do not hesitate to contact me. Yours sincerely Nicola McQueen Chief Executive Officer _NHS Professionals Registered Office: NHS Profess é tke Regtstered in England & Wales no. 6704614 ionals Lid, Suites 1A & 1B Breakspear Park, Breakspear Way, Hemel Hempstead HP2 4TZ
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