Prevention of Future Deaths reports · 2020
Regulation 28 report to prevent future deaths, reference 2020-0207, written 15 Oct 2020. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 15 Oct 2020 |
|---|---|
| Reference | 2020-0207 |
| Deceased | Thomas King |
| Coroner | Lincoln Brookes |
| Coroner area | Essex |
| Category | Suicide (from 2015) · Mental Health related deaths · Community health care |
| Organisation named | Essex Partnership University 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 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Essex Partnership University NHS Foundation Trust 1 CORONER I am LINCOLN BROOKES, Area Coroner for the 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. 3 INVESTIGATION and INQUEST On 7/5/2020 I commenced an investigation into the death of THOMAS JEFFERY KING (aged 27). The investigation concluded at the end of the inquest on 9/10/2020 The conclusion of the inquest was: Medical cause of death: I a Asphyxia b Hanging CONCLUSION: SUICIDE 4 CIRCUMSTANCES OF THE DEATH On 28th April 2020 Mr King was found hanging at his home address in an outside toilet. Paramedics were called but sadly Mr King’s death was confirmed at the scene. Police attended and found no evidence to suggest third party involvement in the death. The Court found that Mr King intentionally ended his own life. He had acted impulsively and whilst suffering from very low mood. The Court heard that he had a history of poor mental health which had often deteriorated in moments of crisis linked to his failed relationship with his partner who had obtained a restraining order against him. He had been arrested and sentenced for several breaches of this order (including custody). He also struggled with bereavement following the death of his father. He had been known to mental health services for many years but his contact increased in the months preceding his death whilst coming into contact with the criminal justice system following arrests for the breaches. 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 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) It was the evidence of the author of the EPUT Root Cause Analysis Investigation , that whilst all the other EPUT teams that came into contact with Mr Report, King, such as the Mental Health Liaison Team and the Street Triage Team, used the same software called Mobius with which to record, access and share important information and developments regarding Mr King, one Team, namely the Health and Justice Team did not use this software and instead used software that was incapable of being accessed by the other teams. A consequence of this was that the other teams were wholly unaware of crises and other important information regarding Mr King’s mental health that were known to the Health and Justice Team. (2) Whilst it was the view of the RCA author that in Mr King’s case such an obstacle to the sharing / accessing of important information did not have a direct bearing on the outcome for Mr King, she did expressly state, and I share this concern, that there is the potential for the wellbeing and lives of other individuals to be jeopardised where important information and / or crises are known to and recorded by the Health and Justice Team but unknown to all the other relevant Teams. There is the potential for the risk of harm to self and others, including death, to be inaccurately assessed and managed where the assessor does not have access to the full picture. (3) The RCA author was not aware as to why the Health and Justice Team had different software to Mobius or why it was not capable of integration with Mobius, but she felt, and I agree, that action should be taken, if it has not already happened, to explore this issue and to implement a solution. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe Essex Partnership University NHS Foundation Trust has 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 4pm 11/12/2020]. 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 Person: (mother of the deceased). 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 DATE: 15/10/2020
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.
8th December 2020 Private and Confidential Lincoln Brookes Area Coroner Coroner’s Office Seax House Victoria Road South Chelmsford CM1 1QH Dear Mr Brookes, 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 15th October 2020, which was issued following the inquest into the death of Mr Thomas King. I would like to begin by extending my deepest condolences to the family of Mr King. 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 issue of concern raised in your report. In response to the matter of concern regarding the potential for the wellbeing and lives of other individuals to be jeopardised where important information and/or crises are known to and recorded by the Health and Justice Team but are unknown to all other relevant teams as they do not have access to the same casenote recording systems. I can confirm that the Health and Justice Service use a recording system called Exelicare which was procured by NHS England. We are contracted by NHS England to provide this service and as part of the contract we are required to use this system to record patient information. The Trust has been working on its strategy to ensure that patient data is accessible by clinicians no matter what system the data is collected on. To ensure this type of incident does not happen again, the Trust has implemented an interoperable application called Tiani Health Information Exchange (HIE) which ensures that a central data repository can be accessed by clinicians to view patient data from across systems. The HIE holds data for patients accessing EPUT services and will also be the tool used to share information across organisations as part of the shared care record for the three STP’s across Essex. All clinical staff in the Trust now have access to the HIE. 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
See every Prevention of Future Deaths report matching Essex Partnership University NHS Foundation Trust, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.