Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0484, written 27 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 | 27 Nov 2019 |
|---|---|
| Reference | 2019-0484 |
| Deceased | George Rogers |
| Coroner | Joanne Andrews |
| Coroner area | West Sussex |
| Category | Suicide (from 2015) |
| Organisation named | Sussex Partnership NHS Foundation Trust |
| 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) ANNEX A 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: 1. The Chief Executive Sussex Partnership NHS Trust 1 CORONER I am Joanne Andrews, assistant coroner, for the coroner area of West Sussex. 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 11 September 2018 I commenced an investigation into the death of George Edward Rogers, 30. The investigation concluded at the end of the inquest on 11 November 2019. The conclusion of the inquest was that Mr Rogers died as a result of an intentional act by him take his own life by causing a fatal laceration to his chest. I therefore gave a conclusion of suicide. 4 CIRCUMSTANCES OF THE DEATH 1. Mr Rogers had a diagnosis of body dysmorphic disorder. He was previously treated for the condition and recovered. He was resident in Australia in 2017 when he started to become unwell again with BDD and returned to the UK in February 2018. 2. On his return to the UK Mr Rogers’ parents took him to his GP who referred Mr Rogers to the Acute Treatment Service (ATS). 3. Before that referral could take effect Mr Rogers attempted to take his own life by causing a laceration to his chest which resulted in an admission to Southampton General Hospital. This was a life threatening injury. 4. On discharge from Southampton General Hospital on 23 February 2018 Mr Rogers the Crisis Resolution and Home Treatment Team was placed under the care of (CRHTT). 5. Mr Rogers was treated by the CRHTT until he was transferred to the care of the ATS on 9 April 2018. On transfer between CHRTT and ATS Mr Rogers was not appointed a Lead Practitioner to coordinate his care. 6. Mr Rogers was assessed by ATS on 11 April 2018. Mr Rogers heard nothing more from ATS until 23 April 2018 following his family’s intervention having heard nothing. A Lead Practitioner was appointed on 23 April 2018. Mr Rogers was not receiving treatment or being seen by ATS between 11 April 2018 and 14 May 2018 and had no treatment or ongoing assessment of risk during this period. It was accepted in evidence by Sussex Partnership NHS Trust that the lack of appointment of a Lead Practitioner for Mr Rogers resulted in delay in his treatment. 7. Mr Rogers received treatment from ATS up until his death on 28 August 2018. 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 could 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. When transferring patients between the CHRTT and ATS there is not always a Lead Practitioner appointed on transfer which may (a) delay patients receiving treatment and (b) mean that patients may not be monitored pending the appointment. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you and 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 10 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 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 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 Joanne ANDREWS Assistant Coroner for West Sussex Coroner's Service Dated: 21/11/2019
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.
A member of: Association of UK University Hospitals Ms J Andrews Assistant Cornoer Coroner's Office Centenary House Durrington Lane Worthing BN13 2PQ Dear Ms Andrews Sussex Partnership Trust NHS Swandean Arundel Road Worthing West Sussex BN13 3EP Re. Inquest into the death of George Edward ROGERS I write further to the inquest of George Edward Rogers which concluded on 11.11.2019 and the Regulation 28 Report to Prevent Future Deaths. The Report concern is as follows: 1. When transferring patients between the CRHTT (Crisis Resolution and Home Treatment Team) and the ATS (Assessment and Treatment Service) there is not always a Lead Practitioner appointed on transfer which may (a) delay patients receiving treatment and (b) mean that patient may not be monitored pending appointment. I will address both points raised in turn, as follows: (a) Allocation of a Lead Practitioner of patients transferred from the CRHTT and ATS The process for allocation of a Lead Practitioner is as follows; the CRHTT attends the weekly Multi-Professional ATS meeting (ATS - sometimes referred to as a Community Mental Health Team) to provide an update on each case and to request allocation, if needed, of a Lead Practitioner. If the patient is already known to the team,·the Lead Practitioner (ATS) will remain involved and work with the CRHTT throughout the episode of care. If the person is unknown to the ATS, the CRHTT and ATS will work together to plan onward care and support. Where a Lead Practitioner cannot be provided immediately by the ATS, an initial appointment will be offered within 7 days of transfer from the CRHTT and follow-up plans will be agreed. This may include care and support being offered by the ATS Duty Worker (a senior registered professional) who the patient will be able to contact for support. This support includes face to face contact on the same day if necessary and attendance at the ATS if Head office: Sussex Partnership NHS Foundation Trust, Swandean, Arundel Road, Worthing, West Sussex, BN13 3EP www.sussexpartnership.nhs.uk A teaching trust of Brighton and Sussex Medical School required. In this instance, the patient and the GP are sent a letter informing them of this plan of care which includes any contact details if there are any concerns. Any patient not allocated a Lead Practitioner is monitored by the Team Leader on a weekly basis. The SPFT Serious Incident report notes that a delay occurred in the allocation of a Lead Practitioner, over a two week period, in April 2018 when Mr Rogers was being transferred between the CRHTT and ATS. As a result of this a new process has been introduced as described above resulting in a 95% reduction in unallocated patients at the point of transfer between teams. I hope that the content of this letter and its enclosures addresses your concerns and provides you with assurance that there is no delay in a patient receiving access to treatment on transfer between CRHTT and the ATS, that there is a process in place to monitor patients who have been transferred and are receiving support with the Duty Worker whilst a Lead Practitioner is identified. However, if any further clarification is required or I can assist further in any way then please do not hesitate to contact me. Yours sincerely Chief Executive
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