Prevention of Future Deaths reports · 2020
Regulation 28 report to prevent future deaths, reference 2020-0196, written 24 Sep 2020. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 24 Sep 2020 |
|---|---|
| Reference | 2020-0196 |
| Deceased | Zak Farmer |
| Coroner | Caroline Beasley-Murray |
| Coroner area | Essex |
| Category | Mental Health related deaths · Community health care |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
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: EPUT 1 CORONER I am Caroline Beasley-Murray, senior coroner, for the coroner area of Essex 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. [HYPERLINKS] 3 INVESTIGATION and INQUEST On 22 July 2019 I commenced an investigation into the death of Zak Miles Joe Walter Paul Farmer a 23 year old man who died on 21 July 2019 at He was found hanging. The investigation concluded at the end of the inquest on 15 September 2020. Braintree I concluded the inquest with a Narrative conclusion:- 4 CIRCUMSTANCES OF THE DEATH See above The medical cause of death was 1a hanging CORONER’S CONCERNS 5 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. There appeared to be a lack of clarity over the meaning of the word “urgent” when a referral is made to the Access and Assessment Team and what steps will be taken if a patient cannot be contacted. 2. The trust document Clinical Guidelines for Community Mental Health Service Users disengaging or non concordant with current prescribed treatment plans was found lacking and requires perfecting. 6 ACTION SHOULD BE TAKEN 1 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 30th November 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 – Solicitors for the family The Castle Rock Group 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 24 September 2020 Caroline Beasley-Murray senior coroner Essex REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (2) NOTE: This form is to be used before an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. 2. 3. CORONER [NAME] [NAME] [NAME] 1 I am [NAME], senior coroner/area coroner/assistant coroner, for the coroner area of [NAME OF AREA] 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. [HYPERLINKS] 2 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: The Castle Rock Group 1 CORONER I am Caroline Beasley-Murray, senior coroner, for the coroner area of Essex 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. [HYPERLINKS] 3 INVESTIGATION and INQUEST On 22 July 2019 I commenced an investigation into the death of Zak Miles Joe Walter Paul Farmer a 23 year old man who died on 21 July 2019 at The investigation concluded at the end of the inquest on 15 September 2020. Braintree. The conclusion of the inquest was expressed as a Narrative viz:- CIRCUMSTANCES OF THE DEATH See above The medical cause of death was 1a) hanging CORONER’S CONCERNS 4 5 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.Mr Farmer had spent some time, during his custodial sentence at HM Prison Chelmsford as a patient at the medium secure unit at Brockfield House pursuant to s48 MHA 1983. There appears to have been a failing in CRG’s procedures for obtaining information from the hospital following the discharge so that a prisoner receives his prescribed medication. 2. There appears to have been a failing in CRG’s procedures to ensure3 that a prisoner is released with discharge information relating to diagnoses. prescription and care plan details. 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. 1 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 30th November 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 – Solicitors for the family EPUT 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 24 September 2020 Caroline Beasley-Murray senior coroner Essex REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (2) NOTE: This form is to be used before an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. 2. 3. CORONER [NAME] [NAME] [NAME] 1 I am [NAME], senior coroner/area coroner/assistant coroner, for the coroner area of [NAME OF AREA] 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. [HYPERLINKS] 3 INVESTIGATION On [DATE] I commenced an investigation into the death of [NAME, AGE]. The 2
2 responses 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.
8 Tiger Court Kings Business Park Prescot Merseyside L34 1BH Phone: Fax: Email: Web: 0174 445 2980 0845 680 1619 info@crg.uk.com www.crg.uk.com Private and Confidential Mrs Caroline Beasley-Murray HM Senior Coroner for Essex SEAX House Victoria Road South Chelmsford Essex CM1 1QH 23 November 2020 Dear Madam Coroner, REGULATION 28 REPORT TO PREVENT FURTHER DEATHS I refer to the subject reference which was issued following the inquest into the death of Zak Miles Joe Walter Paul Farmer and which was received by the Castle Rock Group on Monday 5 October 2020. The concerns raised in your report were as follows “1.Mr Farmer had spent some time, during his custodial sentence at HM Prison Chelmsford as a patient at the medium secure unit at Brockfield House pursuant to s48 MHA 1983. There appears to have been a failing in CRG’s procedures for obtaining information from the hospital following the discharge so that a prisoner receives his prescribed medication. 2. There appears to have been a failing in CRG’s procedures to ensure that a prisoner is released with discharge information relating to diagnoses. prescription and care plan details”. In respect of concern number 1 above, a member of the mental health team attends all MHA s117 meetings prior to a prisoner being discharged back to HMP Chelmsford. The information contained within the s117 meeting minutes will determine the pathway, care plan and medicines management for that person. This information is discussed at the weekly multi-disciplinary team (MDT) meeting hosted by the mental health team. Minutes of these meetings are recorded on SystmOne and can be examined if required. The mental health team now have a dual system (SystmOne and a card index system) both of which contain up to date records of current patients being seen by the unit. This provides a safeguard should SystmOne be offline for any length of time. This dual system is audited each week to ensure both are accurate and updated and the ability exists to run reports on the number of patients released from prison on a month by month basis. In the event that a prisoner is transferred from Brockfield House to HMP Chelmsford via court, rather than being directly transferred, any relevant confidential medical information is sent from Brockfield House to the healthcare team at HMP Chelmsford via secure email facility. This secure email facility has replaced the previous postal/fax system that was in place at the time of Mr Farmer’s transfer between the two institutions. The standard and frequency of communication between the mental health team and staff at Brockfield House is very much improved and there is regular dialogue with regards to any prisoner who has spent, or is about to spend, time at that unit. Again, evidence of this communication is available for scrutiny on SystmOne. In conclusion, physical attendance at the s117 meetings, follow-up discussion and planning by the MDT and the use of secure email has markedly improved and standardised the prisoner transfer process. Regarding concern number 2; the process of discharge has changed significantly since CRG took over responsibility for healthcare provision at HMP Chelmsford in April 2019 and the ability now exists for GPs to access clinical notes which are stored and managed on SystmOne. This access is available through ‘NHS Spine’ which is a relatively new development which was unfortunately not available at the time of Mr Farmer’s discharge from prison. In the event that a prisoner does not already have a community-based GP, advice is given by healthcare staff to assist the prisoner with how to register with a community GP. This advice is recorded on SystmOne and is available for examination. A discharge summary (this would include the care plan, medication and diagnosis details), also now accompanies the prisoner on release from prison. Records of the discharge summary are kept on SystmOne and are available for examination. These records are also accessible by GPs through NHS Spine as described above. Additionally, CRG employ a social inclusion representative who has responsibility for ensuring that when a prisoner is discharged, arrangements are made on behalf of the prisoner so that the provision of clinical details and other social arrangements are in place prior to discharge from prison. A record of individual prisoners’ discharge arrangements is stored on SystmOne and is available for examination. The discharge process is monitored and supervised by a senior member of the mental health team. I hope that the explanation of how current healthcare operations described in the paragraphs above differ significantly from the procedures in place immediately after CRG assumed responsibility for healthcare provision at HMP Chelmsford fully answer the concerns you raised in your PFD report. Please do let me know if I can be of any further assistance or indeed if you would like a presentation of SystmOne in relation to the record keeping referred to in the main body of this letter. Yours sincerely CEO CRG Medical Services
26th November 2020 Private and Confidential Caroline Beasley-Murray Senior Coroner Coroner’s Office Seax House Victoria Road South Chelmsford CM1 1QH Dear Mrs Beasley-Murray, Patient Safety Incident Management Team The Lodge Lodge Approach Wickford Essex SS11 7XX Tel: I am writing to set out the Trust’s formal response to the report made under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013, dated 24th September 2020, which was issued following the inquest into the death of Mr Zak Farmer. I would like to begin by extending my deepest condolences to the family of Mr Farmer. This has been an extremely difficult time for them and I hope that my response provides the family, and you, with assurance that the Trust takes their loss seriously and has taken action to address the issues of concern raised in your report. In response to the matter of concern regarding a lack of clarify over the meaning of the word “urgent” when a referral is made to the Access and Assessment Team and what steps will be taken if a patient cannot be contacted; I can confirm that the Access and Assessment Service respond to all referrals in line with nationally accepted guidelines and standards. A crisis response is responded to within 4 hours, an urgent response within 24 hours and a routine response within 28 days. All referrals are triaged by the team to establish the response required and risk ‘red flags’ are used to inform this decision. The ‘red flags’ are as follows: Risk assessment red flags: Gambling issues Drug / alcohol issues Complex social situation e.g. relationship breakdown Financial issues, debt, redundancy Male, middle or younger age High risk occupations – police officers, doctors, farmers, prison officers Complex physical health issues Chronic pain Family concern / contacting services Context and history – have there been multiple recent presentations/referrals? Since April 2020 the Trust has established a separate Crisis Response Service and all crisis referrals are now actioned by this team. In response to the matter of concern regarding the EPUT Clinical Guidelines for Community Mental Health Service Users disengaging or non-concordant with current prescribed treatment plan, I can confirm that this document is currently under review and we will ensure that it is comprehensive and provides clear guidance for staff. I hope that I have provided you with robust assurance that the Trust has taken steps to address the issues of concern in your report, that we are continuing to take action to strengthen the care provided to our patients, and that patient safety is the Trust’s top priority. Yours sincerely, Chief Executive
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