Prevention of Future Deaths reports · 2020
Regulation 28 report to prevent future deaths, reference 2020-0023, written 6 Feb 2020. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 6 Feb 2020 |
|---|---|
| Reference | 2020-0023 |
| Deceased | David Clark |
| Coroner | Neil Cronin |
| Coroner area | Lancashire & Blackburn with Darwen |
| Category | Mental Health related deaths · Community health care |
| Organisation named | Lancashire Care 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.
for Lancashire & Blackburn with Darwen REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: The Chief Executive Officer Lancashire Care NHS Foundation Trust Sceptre Point Sceptre Way Walton Summit Preston PR5 6AW CORONER | am Neil Cronin Assistant Coroner , for Lancashire & Blackburn with Darwen 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. http://www. leqislation.gov.uk/ukpga/2009/25/schedute/5/paragraph/7 http://Awww.legislation.gov.uk/uksi/2013/1629/part/7/made INVESTIGATION and INQUEST On the 37 July, an investigation into the death of David Clark aged 64 commenced. The investigation concluded at the end of the inquest on the 6"" February 2020. The conclusion of the inquest was that he had taken his own life. CIRCUMSTANCES OF THE DEATH The deceased was compulsorily detained at the Orchard Hospital under section 3 of the mental health act. He had a diagnosis of personality disorder. On the 26" June 2019 at around 19.26 hours he left the Orchard on unescorted leave and was found the following morning and in the Lancaster canal. The cause of death was drowning. 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) That documentation in relation to leave was not completed fully and incorrect forms used (2) That the AWOL procedure was not followed. (3) That a handover was not undertaken between Safety and Security workers. (4) That there was a lack of training on policy and procedure. (4) That there remains outstanding an appropriately sufficient action plan. Coroner's Court, 2 Faraday Court, Faraday Drive, Fulwood, Preston, Lancashire, PR2 9NB. Tel 01772 536536 | Fax 01772 530752 6 | ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you 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 2™ April 2020. |, 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: Farleys, Solicitors for the family | 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. Dated 06/02/2020 Signature NS for Lancashire & Blackburn with Darwen Coroner's Court, 2 Faraday Court, Faraday Drive, Fulwood, Preston, Lancashire, PR2 9NB- Tel 01772 536536 | Fax 01772 530752
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.
Lancashire & South Cumbria NHS Foundation Trust Sceptre Point Sceptre Way Walton Summit Preston PR5 6AW Tel: 01772 695300 lct.enquiries@lancashirecare.nhs.uk 16 April 2020 PRIVATE AND CONFIDENTIAL Neil Cronin Assistant Coroner coroners@lancashire.gov.uk Dear Neil Re: Prevention of Future Death Report Following Inquest into the Death of David Clark Please find a response to the regulation 28 you issued to the Trust dated 06 February 2020 along with the action plan. The action the Trust has taken in relation to the matters of concern you raised are summarised below: 1. That documentation in relation to leave was not completed fully and incorrect forms used. Unit Level o The Orchard WM and Matron are auditing compliance with Safety & Security (SaS) documentation weekly (attachment 2). Trust Level o Monitoring and reporting of Mental Health Act documentation - The Mental Health Law Team monitor the status of all detained patients daily and send a daily status report to each ward for review. The report is sent to Responsible Clinicians, Matrons, Ward Mangers, Deputy Ward Managers, Nursing staff, Medical Secretaries, Pharmacy and any additional staff as appropriate (attachment 3). o Section 17 leave - An inpatient safety matrix which will audit this practice at ward level includes a section of Section 17 Leave. The audit tool has been developed and agreed with Ward Managers (attachment 4). However implementation has been paused due to COVID 19 (new target date September 2020) once implemented compliance will be reported on a monthly basis through the Senior Leadership Team. o Work has been undertaken to the new electronic care record RiO which now includes a pre and post leave assessment form. This is in place in Secure Services and is to be rolled out across the Trust by March 2021. o A practice note has been issued to Ward Managers, Lead Nurses and Doctors reminding them of their accountability in following MHA documentation and Trust policy (attachment 5). 2. That the AWOL procedure was not followed. Unit Level: o The Trust policy and procedure for AWOL has been updated and in line with this staff agree with service users the time they will return from leave. If the service user has not returned by the agreed time AWOL procedures are implemented (SaS documentation, attachment 6). o AWOL procedure has been discussed at the Orchard In-Patient Development days and followed up with email to ensure all staff understand new process (email re AWOL procedures, attachment 7). o The Head of Nursing has completed a supervision session with the Ward Manager and Matron. Trust Level: o The Trust policy and procedure for AWOL has been reviewed and reflects the learning from the investigation (attachment 8). 3. That a handover was not undertaken between Safety and Security workers. Unit Level: o The SaS handover has been reviewed and new forms disseminated which include the SaS worker agreeing that the handover has taken place. The SaS paperwork is audited weekly and demonstrates that handovers are consistently being undertaken (SaS handover documentation, attachment 9). Trust Level: o Learning regarding the handover has been shared with the rest of the Trust. SaS handover is part of the Trust’s Safety and Security Procedure and an audit is planned for Q1 2020/21 to ensure that the wards are using the correct documentation and this is being completed appropriately o A rapid improvement event to review the role and to revise documentation, if required, was due to be undertaken in March 2020 however this has been paused due to COVID 19; the new target date is July 2020. 4. That there was a lack of training on policy and procedure. Unit Level: o In-Patient Development days included discussion regarding AWOL procedures (follow up email, attachment 7). o All new staff are inducted to the SaS procedures (attachment 10) Trust Level: o Ward Managers Task & Finish Group established which includes looking at Policy and Practice. o Clinical risk assessment training - A practice note was sent out trust-wide on 31/01/2020 clarifying the training expectations of all mental health staff. Clinical risk training has now been made mandatory for all clinical staff delivering mental health services (attachment 11). 5. That there remains outstanding an appropriately sufficient action plan. The Trust acknowledges that further work needed to be undertaken to the action plan to reflect the additional views of you and Mr Clark’s family. The strengthened action plan is attached. The Trust Quality Committee will oversee this action plan going forward. Furthermore 2 additional actions that have been undertaken: • A debrief with the staff involved in the care of Mr Clark following learning from the inquest on 12 February 2020 has been undertaken. • Learning in relation to this serious incident and the concerns regarding the care of Mr Clark have been shared with the Ward Manager and the Matron in supervision on 19 February 2020 by the Head of Nursing, Mental Health. I am mindful of the impact of the Trust’s response to COVID-19, in the Trusts ability to complete actions in a timely manner, please let me know if you require any further information. Yours sincerely Director of Nursing and Quality Enc Cc: Caroline Donovan, Chief Executive Director of Improvement and Compliance
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