Prevention of Future Deaths reports · 2020
Regulation 28 report to prevent future deaths, reference 2020-0031, written 18 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 | 18 Feb 2020 |
|---|---|
| Reference | 2020-0031 |
| Deceased | Wayne Millett |
| Coroner | Christopher Morris |
| Coroner area | Manchester South |
| Category | Alcohol, drug and medication related deaths · Hospital Death (Clinical Procedures and medical management) related deaths · Mental Health related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
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REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Mr Trevor Torrington, Chief Executive Officer, The Priory Group. CORONER | ah Chris Morris, Area Coroner for Greater Manchester South. | 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 .legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www.legislation.gov.uk/uksi/2013/1629/part/7/made INVESTIGATION and INQUEST On 5" June 2019, | opened an inquest into the death of Wayne Lee Millett, who died at The Priory Hospital, Cheadle on 13" February 2019, aged 46 years. The investigation concluded at the end of the inquest, which was heard from 3 to 10" February 2020, before a jury. A post mortem examination determined Mr Millett died as a consequence of: 1)a) Acute Lung injury b) Aspiration c) Pseudo-obstruction of Small bowel most likely due to Clozapine Toxicity. The jury concluded Mr Millett’s death was drug-related, on the basis that complications of therapeutic use of the prescribed medication Clozapine set in motion a chain of events leading to his death. CIRCUMSTANCES OF THE DEATH Mr Millett had a long history of mental health problems and was a detained patient at The Priory Hospital, Cheadle pursuant to a s37 Mental Health Act 1983 hospital order made by the court. Mr Millett had been diagnosed with paranoid schizophrenia, which proved refractory to treatment. As such, in conjunction with support and non-medical therapies, the mainstay of Mr Millett’s treatment was the anti-psychotic medication Clozapine. The court heard evidence that Clozapine is. reserved for treatment-resistant schizophrenia in the main, as a result of the nature and extent of side effects which can be associated with its use. In Mr Millett’s case, the administration of Clozapine was endorsed by an independent second-opinion doctor. Amongst other things, Clozapine has been associated with a range of gastro-intestinal side effects, ranging from constipation through to more serious problems leading to paralysis of the gut, bowel obstruction, and necrosis of part of the bowel. In 2015 having become acutely unwell, Mr Millett was admitted to an NHS hospital where he was diagnosed with a paralytic ileus / pseudo-obstruction which was thought may have resulted from Clozapine use. As a consequence of this, upon his return to the Priory, a care plan was developed to seek to promote bowel motility, facilitate early identification of serious gastro-intestinal side effects of Clozapine, and to enable Mr Millett to receive prompt emergency treatment if clinical suspicion of bowel obstruction arose (“the Care Plan”). Whilst Mr Millett often complained Oh aidiominal symptoms, there was an escalation in these from 11" February 2019. Notwithstanding this, the Care Plan was not followed, and Mr Millett became increasingly unwell leading to his collapse and death on 13" February 2019. 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 Priory’s own investigation into the circumstances of Mr Millett’s death was notably lacking in meaningful critical analysis of the care and treatment he received, and in particular was fundamentally flawed in that it failed to consider the care given as against the Care Plan despite its obvious central relevance to his death. 2) The above concern, when taken in conjunction with the facts that: a) the evidence before the court confirmed the organisation’s Director of Risk Management, EM bad input into the investigation; and b) the Peripatetic Director of Clinical Services who gave evidence before the court was unable to describe any overarching quality assurance process operating within the organisation in respect of serious incident investigations; This raises significant concerns as to the Priory Group’s ability to learn from serious clinical incidents and to take action accordingly, thus creating a risk of future deaths. 3) The court heard differing evidence from staff working at The Priory Hospital, Cheadle and from the Peripatetic Director of Clinical Services as to what the organisation’s expectations were in respect of care plans, and specifically the degree of adherence which were required to them. In the light of this significant divergence of opinion, it is a matter of concern that the Priory Group has not undertaken any audit of compliance with care plans (either at The Priory Hospital, Cheadle or more generally within the organisation) as a result of Mr Millett’s death, 4) It is a matter of concern that, notwithstanding the cause of death identified on Post Mortem Examination and despite nearly a year having passed since Mr Millett’s death, the organisation has yet to formally review the care plans of all patients prescribed Clozapine, with a view to ensuring each relevant patient has in place a clear plan for monitoring of potential side-effects of the medication, which gives clear and authoritative direction to staff as to how to act if serious complications are suspected. It is a particular matter of concern that this step has not been taken, given the evidence heard from the Peripatetic Director of Clinical Services which suggested this would be a straightforward measure to accomplish, and one which could be completed within 28 days. 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 14" 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 Mr Millett's brother, i I have also sent a copy of my report to a who represented the Priory Group at the inquest. | have also sent it to the Care Quality Commission, the Regional Medical Examiner for North West England, and Salford CCG (as commissioners of Mr Millett’s care) lam 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: Ty 2020 Signature: Tr, Manchester S
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.
,. Friday 5 June 2020 Your reference: 12296/MH By email: coronersmanchestersouth@ukemail.icasework.com Hard copy to: Mr Christopher Morris HM Area Coroner Coroner's Court 1 Mount Tabor Street Stockport, SK1 3AG Dear Mr Morris Re. Wayne Lee Millett P :::,yo :::,•y OROUP OF "-1. COMPANIES ' Trevor Torrington CEO, Priory Group 80 Hammersmith Road London, W14 BUD '(jlj)~~ 11•JUN 2020 HM CORONER MANCHESTER SOUTH I am writing in response to the Regulation 28 Report dated 18 February 2020 issued following the Inquest touching the death of Mr Wayne Lee Millett. Thank you for permitting an extension in respect of providing a reply in light of the very challenging circumstances presented by Covid-19. We have now had time to give due consideration to the concerns raised and our response is provided as per the below. Our investigation We acknowledge that greater emphasis should have been given to analysing the care plan in place for Mr Millett to include the staff's knowledge and understanding of it and that there was a gap between the prescriptive nature of the care plan and staff's adherence to it. We would ask you to please note that: • • • • The SUI report and a long-term patient who had been at the hospital since November 2013 was of an acceptable standard. report convey that overall, the care and treatment provided by staff to Mr Millett, The care plans themselves were of an acceptable standard and were regularly reviewed. As you rightly point out, Mr Millett often had bouts of abdominal discomfort and prior to the incident, these episodes were managed successfully including through the administration ofMovicol. As such, from a practical perspective, staff were managing the risk on a day-to-day basis in accordance with good clinical practice. At the time the investigation was carried out and the report completed, the investigators were not aware of the cause of death as they had not seen the PME report. You will also appreciate that given the nature and timing of an incident investigation and a coronial inquiry, there is sometimes a "mis-match" between the findings of a SUI report and an inquest and even experienced investigators often consider post-inquest - with the benefit of hindsight - that they could have looked at certain matters in more detail or with greater emphasis. A learning organisation In relation to your concern that we are not a learning organisation, please note we continue to invest significant time and resource in making continuous improvements to the services we provide to some of the most clinically challenging mental health patients in the UK. This includes in relation to incident investigations: in March this ye ar, we recruited a highly-experienced serious incidents investigation officer (SIO) with a clear mandate to make improvements to our processes for the benefit of patients and staff including: 1 .. • Ensuring that all SUI reports are completed within 60 days with the full involvement of all stakeholders including relatives and family members; • Delivering training to senior staff who are commissioned to complete investigations and prepare reports to ensure they have the necessary skills to identify key issues and convey those concisely and clearly in their written outputs; • • Strengthening the review process so that all draft serious incident investigation reports are reviewed by a team of senior staff which in all cases includes the Group Medical Director and the Director of Quality. Ensuring that action plans are drawn up based on the recommendations in the SUI report and these are monitored regularly by senior staff at site to ensure learnings are being embedded in clinical practice. More generally in relation to incidents, we have systems and processes in place to ensure we learn from all incidents and near misses as expeditiously as possible. In July 2019, we invested in a new incident reporting tool (Datix) which has assisted us to report incidents more quickly and better analyse them both locally i.e. at each hospital and across the Healthcare Division as a whole. In the event of a very serious incident, we always undertake a rapid review of the case with the aim of taking swift action, where it is deemed necessary, to help reduce the possibility of a re-currence of such incidents and until such time as the completion of the more detailed investigation. We circulate frequent bulletins and messages to our staff about the lessons learnt from incidents and near misses with policies and training courses amended and updated accordingly. The implementation and embedding of any improvement actions is monitored by our Healthcare Division Quality Team who scrutinise incidents themes and trends and where necessary undertake more individualised reviews of patient care. Auditing compliance with patient care plans Please note there are systems in place which ensure that patient care plans are regularly audited. These systems include Ward Managers and the Director of Compliance at each hospital having a responsibility for undertaking regular "spot-checks" by way of completing the monthly Quality Walk Rounds during which the care records of patients are reviewed and evaluated. Our Healthcare Division Quality Team also undertakes a formal annual audit of care plans. The 2020 audit was unfortunately delayed due to the Covid-19 pandemic but was completed last month with the audit results currently being analysed. Patient Clozapine care plans As above, we are very much a learning organisation and we saw the matters raised at the Inquest concerning Mr Millett as an opportunity to review the way in which we manage the prescription and management of Clozapine. We have now allocated a Clozapine learning and development module to all doctors and qualified nurses. We have also issued Clozapine guidelines and an associated care plan "template" which gives clear details on the potential side-effects of the medication and how best to manage those. I trust that the actions outlined above will provide the assurances you seek in respect of this matter. Yours sincerely, Trevor Torrington Chief Executive Officer Priory Group 2
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