Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0412, written 29 Nov 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 Nov 2019 |
|---|---|
| Reference | 2019-0412 |
| Deceased | Connor Davies |
| Coroner | Geraint Williams |
| Coroner area | South Wales Central |
| Category | Hospital Death (Clinical Procedures and medical management) 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.
SOUTH WALES CENTRAL REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Cwm Taf Health Board 1 CORONER I am Geraint Williams Assistant Coroner for South Wales Central 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. http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www.legislation.gov.uk/uksi/2013/1629/part/7/made 3 INVESTIGATION and INQUEST On 23/04/2019 I commenced an investigation into the death of Connor William DAVIES. The investigation concluded at the end of the inquest 29th November 2019. The conclusion of the inquest was On the 13th April 2019 Mr Davies, who had been receiving assistance from Mental Health Services, hanged himself at 11 The Greenways, Maesteg. Cause of death: Hanging, Verdict: Suicide 4 CIRCUMSTANCES OF THE DEATH Deceased last had contact with family 10.4.19. He was seen by his grandfather around 0800 hrs 10.4.19. Today, 13.04.19 deceased's brother has decided to look for Connor as he was becoming concerned for his welfare. Brother and mother attended at 11 The Greenway and gone upstairs. Brother has opened a bedroom door to find deceased sat against a wall with a ligature around his neck. His backside was suspended off the floor, hands were in his pockets, his head was slumped to the right and his tongue was sticking out. Brother has shut the door and told his mother to and ring an ambulance. He has then gone back into the bedroom and removed the ligature from around his brother's neck, laid him onto his back on the floor. He felt for a pulse but could not find one. Ambulance crew arrived. 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 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. – [BRIEF SUMMARY OF MATTERS OF CONCERN] (1) Mr Davies was seen by a consultant psychiatrist in November 2018 and a follow up appointment made for January 2019. That appointment was cancelled and another made for March 2019. That too was cancelled and a further appointment made for June 2019 but before he could attend Mr Davies killed himself. who gave evidence confirmed that when appointments are cancelled there is no clinical input as to the need of individual patients for more urgent referrals and thus a patient who is in serious need of an appointment may ‘fall through the net’ as may have been the case here. told me that he had endeavoured to put in place a system whereby this could be avoided but, to his knowledge, it is not yet operating. I recommend that your Trust consider this potential issue as a matter of urgency. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you Cwm Taf University Local Health board 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 25th January 2020. 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 family who may find it useful or of interest. 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 29/11/2019 Signature (electronic) Geraint Williams Assistant Coroner South Wales Central
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.
Q G IG Bwrdd lechyd Prifysgol H te, | Cunn-Taf Morgantany Your Reffeich cyf: NHS | university Health Board Our Ref/ein cyf 19/3103/INQ Date/dyddiad 23rd January 2020 Tel/ffén 01443 744800 Fax/FFacs 01443 744889 Email/ebost Private & Confidential Dept/adran Concerns Team, Patient Care & Safety Graeme Hughes Her Majesty's Acting Senior Coroner South Wales Central Coroner Area Coroner's Office The Old Courthouse Courthouse Street Pontypridd CF37 1JW Dear Mr Hughes RE: Regulation 28 ~ Connor Davies Thank you for the correspondence dated the 5° December 2019 in relation to the above Regulation 28, which details the areas of concern following the conclusion of the inquest held on the 29'" November 2019 in relation to the death of Connor Davies. Please be assured that the Health Board has taken this matter extremely seriously and an action plan has been developed to address the matters raised during the inquest. A copy of the action plan is attached. You will note that action to address the issues raised are currently ongoing. All outstanding actions are being implemented by the Mental Health Directorate, who will ensure that there is evidence to support the completed action plan which will be monitored through the Service and Health Board Governance structures. I sincerely hope that this information will reassure you that the Health Board has learnt important lessons from the investigation into the care provided to Mr Davies and that effective action is being undertaken to prevent further deaths. I would like to convey once again my deepest sympathy and sincere apologies to Mr Davies’ family for the failings identified. Yours sincerely Ize Choy Dr Sharon Hopkins Chief Executive Officer Enc Return Address: Cwm Taf Morgannwg University Health Board, Headquarters, Navigation Park, Abercynon, CF45 4SN Chair / Cadeirydd; Professor Marcus Longley Chief Executive / Prif Weithredydd: Dr S Hopkins Cwm Taf University Health Board is the operationat name of the Cwm Taf University Health Board/Bwrdd lechyd Prfysgal Cwm Taf yw enw gweithredol Bwrdd lechyd Prifysgol Cwm Taf ACTION PLAN FOR IMPROVEMENT Reference Directorate Lead Officer for Action Plan (name & title) Date action plan commenced Synopsis of Concern Action Needed To review the existing process that determines clinical priority for rebooking of patient appointments following cancellation of clinics across the directorate. Revise the process to ensure that when appointments are cancelled a robust system is in place to triage the patient’s clinical need and prioritise allocation of appointments as required. Ensure that all clinical and administrative staff who are involved in cancelling and rebooking of appointments are trained in the agreed process and that there is an audit trail to demonstrate this. Audit the new process to determine compliance at specific check points as agreed. Regulation 28 Report — Ref17108. MHU ~ W122574 Mental Health Fiona Thomas 15" January 2019 That when appointments are cancelled there is no clinical input as to the need of individual patients for more urgent referrals and thus a patient who is in serious need of an appointment may ‘fall through the net’. Deadline date for Completion Clinical Director | 15' April 2020 Locality 30" June 2020 Managers Progress & Evidence Monitoring Arrangements Management Team Meeting Locality Managers 31* July 2020 31* October 2020 Quality, Safety & Risk Meeting Quality, Safety & Risk Meeting Quality, Safety & Risk Meeting
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