Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0265, written 20 Aug 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 20 Aug 2019 |
|---|---|
| Reference | 2019-0265 |
| Deceased | Tony Dunne |
| Coroner | Mary Hassell |
| Coroner area | Inner North London |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths · Suicide (from 2015) · Mental Health related deaths |
| Organisation named | East London NHS Foundation Trust |
| 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: Prevention of Future Deaths report Tony Mark DUNNE (died 21.02.19) THIS REPORT IS BEING SENT TO: 1. Dr Paul Gilluly Chief Medical Officer East London NHS Foundation Trust Trust Headquarters 9 Alie Street London E1 8DE CORONER lam: Coroner ME Hassell Senior Coroner Inner North London St Pancras Coroner's Court Camley Street London N1C 4PP CORONER’S LEGAL POWERS | make this report under the Coroners and Justice Act 2009, paragraph 7, Schedule 5, and The Coroners (Investigations) Regulations 2013, regulations 28 and 29. INVESTIGATION and INQUEST On 25 February 2019, one of my assistant coroners, Edwin Buckett, commenced an investigation into the death of Tony Mark Dunne. The investigation concluded at the end of the inquest yesterday. | made a determination of suicide. The medical cause of death was: 1a multiple traumatic injuries. CIRCUMSTANCES OF THE DEATH Tony Dunne had alcohol dependence disorder and also extreme anxiety & mild depression. He jumped from a 7" floor window late on the evening of 20 February 2019. He had been seen by a mental heaith nurse at Homerton University Hospital emergency department earlier that evening, having been found by police beside an 8" floor window intending to jump, but had refused informal admission and was deemed not detainable under a section of the Mental Health Act. He rang the Crisis Line a little over an hour after discharge. He was not asked if he was feeling suicidal and he rang off after 5 minutes. 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. Mr Dunne rang the Crisis Line a little over an hour after he had been discharged from the emergency department. He had been seen at the emergency department because he had been found by police standing by an 8" floor window intending to jump. The Crisis Line call taker read his medical notes and so knew this history, but nevertheless did not ask him if he was now feeling suicidal. If she had asked him and he had said yes, she could have asked him to come in to the hospital again or she could have called an ambulance for him. ACTION SHOULD BE TAKEN In my opinion, action should be taken to prevent future deaths and | believe that you 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 21 October 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 following. HHJ Mark Lucraft QC, the Chief Coroner of England & Wales Care Quality Commission for England Ee Parents of Tony Dunne HE other of Tony Dunne | 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 Senior Coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. DATE SIGNED BY SENIOR CORONER 20.08.19 ‘ MEHL olf
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.
East London NHS Foundation Trust Pleas Associate Director of Legai Affairs. Trust Headquarters. 9 Alie:Street London _ EV 8DE Telephone: 0207 655.4064 21 -Qctaber 2019 Coroner ME Hasseil Senior Coroner Innér North London ; St Parieras Coroner's Court Camley Street London NiC 4PP Dear Madam Inquesttouching upon. the.death of Tony Dunne This isa formal resporise to:-your Regulation 28 Report dated :20 August 2019 in which you set out your concems relating to the care Mr Dunne received from:East Londén NHS Foundation Trust (the Trust). Your concerns. related to Mr Dunne’s assessment ‘carried out by the.registered mental health nurse (RMN) when Mr Dunne-called the City and Hackney Crisis.and Resolution Home Treatment Team's. (City. and Hackney HTT). crisis line ori 20 February 2019 at 22:51. In:particular, you note that.it was only over an hour since Mr Dunne was discharged from A&E, yet the RMN did net ask Mr Dunne if he- felt sulcidal. Jam Aware that, you heard evidence during the course of the Inquest that the RMN believed that she had asked Mr Dunne if he. was-Suicidal during her’assessment as it was her usual practice. However, she:could not specifically recall if she-had. Further, she had not made a full reeordiiig it: Mr Dunne’s. medical notes of her assessment: We understand that without a ‘full note you cannot be reassured that 4 full risk assessment’ was undértaken and that Mr Dunne: was asked if he was suicidal. Given the concern you raised was not identified in the Trust's SI.report we reviewed this matte? in more detail. We further identifie jad that the RMN:went off sick shortly after her phone call with Mr Dunné-and that this likely impacted ypon the quality of her medical note. Chair: Marie Gabriel. Chief Executive: Dr Navina Evans The importance of good quality; full, complete and appropriate risk assessments is:a key skill for all our clinical staff-atithe Trust. In-order to’reinforce. this, the City and: Hackney HTT will be providingadditional training duiing. its away days scheduled.for 4 and 5 December:2019. This will include: , 1) Reviewing ‘the core-competencies and ‘standard of risk assessment.required by clinicians operating the crisis lina in line with the Trust's Competency Framework for Mental Health Crisis Lines; and 2) Reinforcing the standard of medical record taking expected by the crisis line clinicians. in accordance with the Trust's Mental Health Crisis Line Standard Operating. Procedure: Godd quality handover of patient care is also.expécted of our-clinicat staff'at the Trust: including in cases. of sudden illhess. The Gity: and Hackney HTT will alsa be providing: training iti relation:to’this topic, in:accordance with the Trust's. Managing Sickness Absence Policy onits away days on.4-and 5, December 2019. Additionally, the Trust appreciates that in cases of sudderr illness, circumstatices ‘May arise beyond staff members: contro! impacting.the quality of their handover. In order fo:ehsure continuity of care forall of its patients, the City and Hackney HTT will be rolling-out a new protocol:on. checking outstanding work following sickness. Going forward, if-a clinician tanning the crisis line is-suddenly ill, at the first opportunity, that staff: members" immediate line mariager will review their case load forthat shift -and ensure that all appropriate. actions have been taken arid that this is reflected in: the-medical notes. | hope that the information above reassures you that the Trust has taken your concerns seriously and that the action taken has adequately addréssed those concerns. If you do require any further information please. do not hesitate to.contaci me. Youis sincerely Dr Paul Gillutey Chief Medical Officer Chair. Marte Gabriel a Chief Executive: Dr Navina Evans
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