Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0359, written 4 Oct 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 4 Oct 2019 |
|---|---|
| Reference | 2019-0359 |
| Deceased | Jane Livington |
| Coroner | Aled Gruffydd |
| Coroner area | Swansea Neath & Port Talbot |
| Category | Mental Health related deaths · Suicide (from 2015) · Wales prevention of future deaths reports (2019 onwards) |
| 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 FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
CHIEF EXECUTIVE ABMU HEALTH BOARD
1 TALBOT GATEWAY
BAGLAN ENERGY PARK
BAGLAN
PORT TALBOT
SA12 7BR
1
CORONER
I am Aled Gruffydd, Assistant Coroner, for the coroner area of SWANSEA NEATH &
PORT TALBOT
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 the 24th December 2018 I commenced an investigation into the death of Jane Diane
Livingston. The investigation concluded at the end of the inquest on the 30th September
2019.
The medical cause of death is
1a
pressure of the neck consistent with hanging
The conclusion of the inquest as to how Ms Livingston came to her death is suicide and
is as follows:-
The deceased was pronounced dead on the 23rd of December 2018 at the multi story
car park on Trawler Road, Swansea. The deceased died from pressure of the neck
consistent with hanging. The deceased had taken her own life. The deceased had
suffered with anxiety and depression for twenty years which deteriorated from November
2018 onwards. The deceased was referred for a Gateway Assessment which placed her
under the care of the Assessment and Home Treatment Team on the 21/22 December
2018. The assessment was appropriate and there were no grounds to detain the
deceased under the Mental Health Act 1983.
4
CIRCUMSTANCES OF THE DEATH
The deceased was Jane Diane Livingston and she was pronounced dead on the 23rd of
December 2019 at the multi storey car park on Trawler Road, Swansea. The cause of
death was suicide after she was found hanging at the above location.
Jane was receiving treatment for mental illness by the Community Mental Health Team
1
(CMHT) and the Assessment and Home Treatment Team (AHTT). Jane was diagnosed
as having depression and anxiety. Her condition was managed by her General
Practitioner for twenty years until her condition deteriorated in November 2018
Jane was reviewed by a Psychiatrist on the 8th of November and was given a treatment
plan recommending treatment in the Community. This plan was complied with and Jane
was discharged from the crisis team on the 26th of November 2018 however remained
under the care of CMHT. The evidence of the Community Psychiatric Nurse (CPN) was
that on the 14th of December 2018 Jane had been reviewed by CMHT, who referred her
to Cefn Coed Hospital for a gateway assessment that was conducted on the same day
to determine which pathway her treatment would follow. During that review Jane stated
that she wanted to be referred as a voluntary patient at hospital since if she was left at
home she would contemplate suicide. During the gateway assessment this was not
mentioned and the CPN conducting the gateway assessment was unable to access the
CMHT review as it had not been uploaded onto the case management system. The
deceased went on to have further assessments in which the CMHT review subsequently
became available on the case management system.
5
CORONER’S CONCERNS
During the course of the inquest it was apparent that the deceased’s wishes for hospital
treatment and the reasons behind the same were not available to the gateway
assessors on the 14th of December 2018. In this case the deceased underwent further
assessments therefore the effects of this situation were reduced. I am concerned
however that in other cases this could result in situations where a patient’s own
concerns are not addressed or taken into consideration when conducting an
assessment that could lead to an assessment based on incomplete information and
result in another patient taking their own life. 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. –
1. The gateway assessors did not have full access to the notes relating to the
review and subsequent concerns that triggered the gateway assessment. This
may result in the assessors not obtaining the full picture when assessing a
patient and making a treatment plan based on incomplete information.
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 29 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.
8
COPIES and PUBLICATION
I have sent a copy of my report to the Chief Coroner and to the following Interested
Persons
.
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
2
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
4 October 2019 ………………………………. [SIGNED BY CORONER]
3
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.
Bwrdd lechyd Prlfysgol Bae Abertawe Swansea Bay Univenlty Health Board gofalu am eln gllydd, ~lthlo, gwella bob amHr caring for uch ott.r, working tos,.th•r, alwiliys Improving Pancadlyll Bwrdd lechyd Prffyagol B•• Abertawe HNdquartlra Un Porthfa Talbot, Pare Ynnl, Baglan, Port Talbot, SA12 7BR SwanaM Bay Untverelty HNlth Board H ..dquartera One Talbot Gateway, Baglan Energy Parle, Port Talbot, SA12 7BR Rydym yn croeaawu goheblaeth yn y Gymraeg ac yn y Saeaneg. We welcome correspondence in Welsh or EngHsh. Date: 23"' November 2019 Dear Mr'Gruffydd, RE - Regulatlon 28 Response -Jane Livingston I write further to your letter dated 4th October 2019, enclosing the Report to Prevent Future Deaths following the inquest held into the death of Jane LMngston on 30th September 2019 where the conclusion reached was suicide. Thank you for providing us with an opportunity to review the Issues that your report raises. I can conflnn that a detailed review of the information in the report has been undertaken by the Quality and Safety team for the Mental Health Swansea locality at Swansea Bay University Health Board. A full Investigation has been conducted into the events of the 14th December and can be outlined below: • The Community Mental Health Team (CMHT) conducted a Duty Assessment on Ms LMngston on 14th December 2018 and deemed that Ms Livingston required further assessment by the Assessment and Home Treatment Team (AHTT) at Cefn Coed Hospital. On completing the duty assessment, the CMHT staff documented the assessment on to the eledronic social care system (PARIS). I understand that the Coroner's concerns were that this review had not been uploaded onto the electronic case management system before the AHTT gatekeeplng ·Bwrdd lechyd F>rtfyagol Bae Abertawe yw enw gwelthredu Bwrdd lechyd Lleol Prifysgol Bae Abertawe Swansea Bay Univeralty Health Board is the operational name of Swansea Bay Unlveralty Local Health Board assessment. As such, this could create a situation where an assessment takes place based on incomplete previous information which presented a risk to patients. The Health Board confirms that the PARIS system has been audited during our investigation, and can confirm that the CMHT staff accessed the system at 12.29hrs on the 14th December 2018 to document the duty assessment conducted on Ms Livingston. Please see appendix 1 for assessment. Once the duty assessment had been documented, the CMHT staff contacted the AHTT team via telephone to arrange the AHTT Assessment (gateway assessment). The telephone call involved a verbal summary of the case including the risks identified, requesting an AHTT gateway assessment. The AHTT confirmed acceptance of Ms Livingston, and arranged a gateway assessment as an outcome of the telephone call. The enquiry was accepted and documented on the PARIS system at 14.13hrs (please see appendix 2). The AHTT team completed their gateway assessment of Ms Livingston and accessed the PARIS system at 14.36hrs to document the visit. Please see appendix 3 for the case note entry of this visit and appendix 4 for the assessment. The Investigation Into this matter has identified that the entries made during the first duty assessment were available for the later gateway assessment. It also identified that the assessors in the gateway assessment were aware of Ms Livingston's wishes for hospital treatment. The information documented in the gateway assessment demonstrates the decision making process in respect of Ms Livingston wish to go to hospital, discussing and agreeing treatment options. The duty assessment (appendix 1) was available to the AHTT gateway assessors at Cefn Coed but unfortunately did not form part of the Coroner's Inquest disclosure. The Health Board are extremely sorry for this disclosure omission. Actions to ensure patient notes are avallabla to inform subsequent assessment • Confirmation that the process outlined above is the standard process for referring and arranging gateway assessments and sharing information between services effectively. • Confirmation that the referral process is documented on the system via the enquiry function on the PARIS system. • Confirmation that the PARIS system has the functionality to allow users to access and view the system in real time including when It is being edited by another user. Bwrdd lechyd Prtfysgol Bae Abertawe yw enw gwelthredu Bwrdd lechyd Lleol Prlfysgol Bae Abertawe Swansea Bay University Health Board la the operational name of Swansea Bay University Local Health Board Action to ensure that Coroner has access to all patient records for Inquest • When requesting a copy of mental health notes, a specific request is now also made for all PARIS electronic records by the Corporate Legal Team. • The Mental Health Quality and Safety team will identify all the possible locations of patient records across mental health Services, this information will be used to develop a checklist, which can be used to audit the completeness of records prior those records being disclosed to HMC Coroner. This will be completed by 21 81 December 2019. I hope that the information provided within this response by the Mental Health and Leaming Disabilities Delivery Unit has provided assurance to the HMC Coroner that the risks identified in the Regulation 28 report on the death of Jane Livingston are adequately explained, and that learning around dlsclosure going forward has been addressed. Yours sincerely Chief Executive Appendices 1. CMHT CPA assessment 14/12/2018 2. AHTT Enquiry 14/12/2018 3. AHTT case note entry 14/12/2018 4. AHTT CPA assessment 14/12/2018 Appendix 1 • CMHT assessment 14.12.20 Appendix 2-AHTT enquiry 14.12.2018.f Appendix3-AHTT case note entry 14.1 Appendix 4 • AHTT CPA assessment 14. Bwrdd lechyd Prlfysgot Bae Abertawe 'fN enw gwalthredu Bwrdd lechyd Lleol Prlfyagol Bae Abertawa Swanaea Bay University Health Board is the operatlonal name of Swansea Bay University Local Health Board
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