Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0357, written 11 Sep 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 11 Sep 2019 |
|---|---|
| Reference | 2019-0357 |
| Deceased | Maureen Jarvis |
| Coroner | Andrew Haigh |
| Coroner area | Staffordshire (South) |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths · Mental Health related deaths |
| Organisation named | Midlands Partnership University 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 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Mr Neil Carr OBE Chief Executive Midland Partnership Foundation NHS Trust Mellor House Corporation Street Stafford ST16 3SR = CORONER | am Mr Andrew Haigh senior coroner for the coroner area of Staffordshire South 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. INVESTIGATION and INQUEST On 24 August 2018 | commenced an investigation into the death of Maureen Margaret Jarvis aged 72 years. The investigation concluded at the end of the inquest on 10 September 2019. The conclusion of the inquest was ‘naturally occurring ulcer that was not diagnosed until after it had burst’ with the death having resulted from a perforated duodenal ulcer. CIRCUMSTANCES OF THE DEATH (a) Maureen Margaret Jarvis (known as Mandy) was compulsory detained under section 3 of the Mental Health Act at the George Bryan Centre (GBC) Tamworth. On the 15'" August 2018 she was taken to Good Hope hospital where she died on the 17" August 2018 due to the effects of a burst ulcer. (b) At times staff at GBC were aware of Mandy being in pain. A full physical examination did not take place on admission although this was policy, nor at any other time during the rest of her time at GBC. Mandy did not provide her consent and it was deemed not appropriate to force her. The lack of full physical examination is a possible causative factor in her death. A further consideration is the failure to keep correct and accurate records. The level of personal care Mandy received could have been improved. CORONER’S CONCERNS During the course of the inquest the evidence revealed a matter 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 MATTER OF CONCERN is as follows. — During her final admission to the George Bryan Centre Mrs Jarvis did not have a proper medical examination by a doctor. The reasons given for this were that she would not consent and that her condition never warranted this being done on a non- consensual basis. Among other witnesses | heard helpful evidence from the Consultant Psychiatris ho indicated that this was a difficult area and also from SM (the lead author of the Serious Incident Review) who believed there was a policy about this but could not be specific. It strikes me that there should be a clear policy about physical health examination of admitted psychiatric patients and this should be disseminated to all staff involved. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you and your organisation 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 6 November 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. COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the following Interested Persons: Irwin Mitchell solicitors for the Jarvis Family Capsticks solicitors for your Trust. | have also sent it to the following persons who may find it useful or of interest: Care Quality Commission University Hospitals Birmingham NHS FoundationTrust. | 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. 11 September 2019 | oa Andrew A Haigh HM Senior Coroner for Staffordshire (South) Coroner's Office No 1 Staffordshire Place Stafford ST16 2LP Tel No: 01785 276127 sscor@staffordshire.gov.uk
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) Midlands Partnership NHS Foundation Trust A Keele University Teaching Trust Neil Carr Chief Executive Trust Headquarters St George’s Hospital Corporation Street Stafford ST16 3SR Tel: 0300 790 7000 Mr A Haigh HM Senior Coroner for Staffordshire (South) Coroner’s Office No 1 Staffordshire Place Stafford ST16 2LP 17" October 2019 Dear Mr Haigh, RE: Maureen Margaret (known as Mandy) Jarvis Thank you for your letter dated 11" September 2019, reporting a matter to us, in accordance with Regulations 28 and 29 of the Coroner's (Investigations) Regulations 2013. May | take this opportunity to reassure you that following Mrs Jarvis’ death, we undertook a thorough investigation into the care delivered by the Trust. Following discussions both within the mental health Services in the Staffordshire and Stoke Care Group and across the wider Trust, | am now in a position to respond to your specific concerns, raised by you during the course of the evidence you heard at the inquest. 1. Area of concern; “during her final admission to the George Bryan Centre Mrs Jarvis did not have a proper medical examination by a doctor. The reasons given for this were that she would not consent and that her condition never warranted this being done on a non- consensual basis. Among other witnesses | heard helpful evidence from the Consultant Psychiatrist who indicated that this was a difficult area and also fro (the lead author of the Serious Incident Review) who believed there was a policy about physical health examination of admitted psychiatric patients and this should be disseminated to all staff involved.” In response we can confirm that a policy and Standard Operating Process (SOP) existed at the time of Mrs Jarvis’s death. These outline the responsibilities and expectations of inpatient staff to undertake physical health investigations on admission and also the expectation in the circumstance of refusal to consent to continue to attempt during the NHS) Midlands Partnership NHS Foundation Trust A Keele University Teaching Trust admission. These documents are currently due for review as part of the continuous improvement and ratification cycle. Following changes in recording of investigations in our electronic health record system further guidance was developed to sit alongside these SOP’s. mental | can confirm that these documents have been circulated to all the staff on our health inpatient wards and are being referenced in new inpatient staff local inductions. In addition several actions have been completed to further enhance the physical health care of our patients admitted to our mental health units. These include: > Please The ward staff on Milford Unit (previously the George Bryan Centre West Wing) have undertaken bespoke training in order to further develop their knowledge and understanding of common physical health difficulties. An electronic dashboard has been developed to provide an “at a glance” view of whether key physical health assessments and investigations have been completed and recorded on the electronic health record in the appropriate form. This is utilised in clinical discussions on the ward as a live audit tool. The ward has secured regular input from an Advanced Nurse Practitioner to specifically to support the physical health needs and monitoring of patients on the ward. Ward staff reminded to record consent and/or lack of capacity to consent to a physical health assessment within RiO and if either lacking preventing assessment to regularly revisit and record attempts. Dissemination of the Physical Health Policy and SOP as part of the junior doctors induction find enclosed a copy of the full action plan developed as a result of the investigation. | hope this response helps to address your concerns. However, if you require any further information please do not hesitate to contact me Yours sincerely z t eil Ca Chief Executive MPFT
See every Prevention of Future Deaths report matching Midlands Partnership University NHS Foundation Trust, 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.