Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0478, written 26 Feb 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 26 Feb 2019 |
|---|---|
| Reference | 2019-0478 |
| Deceased | Keith Heatley |
| Coroner | Ian Boyes |
| Coroner area | South Wales Central |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths · Wales prevention of future deaths reports (2019 onwards) |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
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ANNEXA 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: The Chief Executive ABMU Health Board CORONER | am lan Boyes, Assistant Coroner, for the coroner area of South Wales Central 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 t concluded an inquest on 26'" February 2019 into the passing of Mr Keith Heatley. The medical cause of death was 1a. Drowning and the conclusion of the inquest was an open conclusion. CIRCUMSTANCES OF THE DEATH | find the fact that Mr Heatley was admitted voluntarily to hospital on 1% May 2018 and thereafter was transferred to Ward 14 on 3% May 2018. | find that upon admission that he needed urgent admission and in] view which | accept that at the time of admission on 1% May 2018 he was considered a high tisk of suicide, potential risk to his wife and possibly psychotic. | find the fact that during the time Mr Heatley remained on Ward 14 he enjoyed various amounts and degrees of leave from the hospital grounds. This varied between leave within the hospital grounds and leave outside the hospital grounds with his family | find that there was a lack of documented evidence of multidisciplinary decision-making and planning of Mr Heatley's leave from the ward. | find that the time of writing the serious incident clinical review there was no policy guidance within the mental health and learning disability delivery unit regarding leave for informal patients. | find as a fact that although multidisciplinary team meetings were held on the 8" and 15" of May they were not documented directly in the clinical notes but were instead documented in pro formas intended to be added to the clinical record. | accept the evidence a there was a lack of consistent recording of MDT meetings within the clinical notes particularly for the 8" and 15" of May 2018. | find as a fact that there is no evidence of anyone agreeing or authorising leave for Mr Heatley on 18%" May 2018. | find as a fact that even if there was a decision made to grant and authorise leave Mr Heatley on 18 May 2018 there was no clinical review of him prior to him leaving the hospital that day. | find as a fact | find the fact that the risk of suicide and/or self-harm was real and ever present. In real terms this simply means that this was not a fanciful whim or suggestion | find that Mr Heatley left the family home at some time in the afternoon of 18" May and thereafter was found in the water. | find that Mr Heatley sadly passed away as a result of drowning. | accept the medical cause of death as propounded by which is supported by the evidence or a concerning the blood/water fluid on the lungs. It is not suggested Mr Heatley passed away as result of any other cause. There is simply no evidence before me as to how Mr Heatley entered the water | find that | cannot be satisfied on the evidence that the conclusion of suicide is appropriate or merited. The evidence does not show a causal link between those facts as | have found in relation to the care and the passing it follows the state could not be in breach of its obligations under article 2 to protect life. The inquest focused on the leave given to Mr Heatley as a voluntary patient, the systems in place to authorise and review the same and the support given to families upon a voluntary patient enjoying home leave. 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. — (1) The evidence of a Consultant Psychiatrist who was a Clinical Advisor to a Significant Incident Review stated that there was a policy in England for reviewing and assessing patients who are voluntarily admitted to hospitals before they go on home leave. There is no such policy or procedure in Wales. (2) As a result of there being no policy in Wales, hospital doctors and Nursing staff are reliant on ‘best practice’ however this concept is not defined nor does it provide a sufficient level of guidance for patients and staff. (3) There were no or insufficient procedures in place for hospital staff to liaise with the patient's family and CPN when leave is considered to examine the preparedness of the family and whether there were systems of support in place. 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 23% April 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 family, Health inspectorate Wales and Welsh Government, who may find it useful or of interest ! am also under a duty to send the Chief Coroner a copy of your response nN 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. 26" February 2019 SIGNED: | D Boyes- Assistant Coroner (Electronic signature) we
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 Prifysgol Cadelrydd/Chairman: Andrew Davies a GIG Bae Abertawe Prif Welthredwr/Chief Executive: Tracy Myhill Fi S | Swansea Bay University gofalu am ein gllydd, cydwelthio, gwella bob amear wares | Health Goard caring for each other, working together, always improving Pencadiys Bwrdd lechyd Prifysgol Bae Abertawe Un Porthfa Talbot, Pare Ynni, Bagian, Port Talbot, SA12 7BR + Ffén 01639 689334 Swansea Bay University Health Board Headquarters One Telbot Gateway, Bagian Energy Park, Port Talbot, SA12 7BR Phone 01839 683334 Rydym yn croesawu goheblasth yn y Gymraeg ac yn y Saesneg. We welcome correspondence In Welsh or English. @ 01639 683374 Dyddiad / Date: 23" April 2019 Mr1D Boyes Assistant Coroner Comer Office The Old Court House Courthouse Street Pontypridd CF37 1JW Dear Mr Boyes Re: Kelth Heatley — deceased | write with reference to the Inquest held on 26" February 2019 In respect of the above named. During the inquest you issued a Regulation 28 Report to Prevent Future Deaths. The Regulation 28 Report related to the fact that there was no policy or procedure in place in Wales to review and assess informal patients prior to them going on leave from the Ward. The Health Board accepts that Mr Heatley's leave should have been managed better and has implemented a checklist to ensure mult-disciplinary team members including the Community Mental Health Team and the patient’s family ara aware and able to express their views on the leave, prior to the patient going on leave away from the Ward. In addition the Health Board has taken a number of steps to improve patient safety within mental health services which includes: © Appointment of a ward clerk to support timely documentation of Multi-Disciplinary Team meetings for Ward 14; e Development of a carers’ forum within Bridgend which meets monthly. Bwrdd lechyd Prifyegol Bae Abertawe yw anw gweithredu Bwrdd lechyd Lieol Prifysgol Bae Abertawe Swansea Bay University Health Board is the operational name of Swansea Bay University Local Health Board Implementation of the Wales Applied Risk Research Network (WARNN) risk assessment model as one fool for use within the service. Staff on ward 14 attending ongoing training regarding WARNN risk assessment. Implementation of the mental health Patient Experience Group (PEG) which covers all areas of service covered within the Bridgend Locality, which includes Inpatients services, Involvement of carers’ representatives In the 15 steps reviews caried out on ward 14, Colty Clinic, Bridgend. Staff have and will continue to receive training In formulation of Care Plans with Involvement from the patient's perspective. Lead staff are working with ward staff in relation to Information sharing with families in relation to the patient's care, while still adhering to patient’s wishes and rights. A leaming event has been arranged with the Mental Health Team to share the learning within the Health Board on 26% April 2019. The Health Board will then share the leaming on an all Wales basis through the Heads of Patient Experience Network in June 2019. Furthermore, the Health Board Is taking advice on the policies In place in England in terms of ensuring the Welsh legislation Is complied with, Mental Health Measure 2012, which Is not applicable In England. Consideration will also be given to balancing the fact that they are voluntary patients and we cannot deprive these patients of thelr liberties. Once the Health Board has developed a policy then It will be shared on an all Wales basis to ensure leaming from this case Is shared across NHS Wales. Yours sincerely Tray My ol Tracy Myhlill Chlef Executive cc Improving Patient Safety Team, Welsh Government cote vty gofalu am ein gliydd, cydweithio, gwella bob amser caring for each other, working together, always improving Page 2
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