Prevention of Future Deaths reports · 2020
Regulation 28 report to prevent future deaths, reference 2020-0214, written 23 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 | 23 Oct 2020 |
|---|---|
| Reference | 2020-0214 |
| Deceased | Benjamin Popovach |
| Coroner | Ian Arrow |
| Coroner area | Plymouth, Torbay and South Devon |
| Category | Mental heath related deaths · Other related deaths |
| Organisation named | Devon Partnership NHS 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 THIS REPORT IS BEING SENT TO: Chief Executive Officer of Devon Partnership NHS Trust 1 CORONER I am Ian Michael Arrow, Senior Coroner for Plymouth Torbay and South Devon 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. http://www. legislation. gov. u k/u kpg a/2009/25/sched u le/5/parag raph/7 http://www.legislation.gov. uk/uksi/2013/1629/part/7 /made 3 INVESTIGATION and INQUEST Following an Inquest opened on 3 April 2020 and a hearing on 9 October 2020 in the HM Coroner's Court, Plymouth I found that Benjamin Popavach had died as a result of:- 1 (a) Drowning 4 CIRCUMSTANCES OF THE DEATH The deceased was on home leave from a mental health unit where he was a voluntary patient. He could not be contacted by medical staff and his body was subsequently found in the sea off Corbyn Head, Torquay. The Coroner recorded an Open conclusion. 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 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 Coroner has seen a copy of the Root Cause Analysis dated 27 March 2020. Your reference number RMS: - au tho r - (2) At Page 20 of the Root Cause Analysis there is an outcome of the review listed under Immediate Changes - Ensure risk assessments are completed for patients going on leave, which identify risks in the community and agreed actions to be taken by staff in case of a breakdown in plan Sharing the learning - To be shared with Ward Staff and Community Teams 6 ACTION SHOULD BE TAKEN In my opinion, action should be taken to prevent future deaths and I believe you have the power to take such action to put those recommendations into effect. I should be obliged if you would confirm that action has been taken to put those recommendations into effect. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 15 December 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, the family. 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 Dated ;p:s •( o ' ....__:) Signature ____ ~t/!L_"'--------
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.
Mr Ian Arrow
Senior Coroner for Plymouth, Torbay and
South Devon
Plymouth Register Office
1 Derriford Business Park
Plymouth
PL6 5QZ
Trust Headquarters
Wonford House Hospital
Dryden Road
Exeter
EX2 5AF
Telephone:
Web: www.devonpartnership.nhs.uk
Your Ref:
Our Ref:
14 December 2020
Dear Mr Arrow
Re: Benjamin Popavach (deceased) - Inquest 9 October 2020
Regulation 28 Report to Prevent Future Deaths
Thank you for your letter of 23 October 2020 following the inquest into the death of Benjamin
Popavach. As an organisation we are committed to learning from these tragic events and
have since receiving your report and recommendations taken the opportunity to share your
findings with the service involved as well as across the wider trust.
The Trust has undertaken a Serious Incident Investigation following the death of Benjamin;
the report was shared at the inquest and I can confirm that the action plan developed in
response to the RCA investigation has been progressed.
Your report requested the Trust confirm that the actions identified in the Serious Incident
Investigation have been progressed.
Following review of your report and consideration of your recommendations we have reviewed
our action plan. The areas of learning identified in the report are detailed below with the
actions that were proposed to address these.
Outcome of Review
Issue
Description
Areas for Learning
Ben’s history suggested he could be very high risk when
in the community, given his family history, repeated
pattern of stopping or reducing his medication, being hard
to engage, relapse, and self-harm attempts in May 2019
and January 2020.
He was repeatedly assessed as low risk on the ward. No
additional risk assessment was done to identify the
possible and likely risks when back at home, and to plan
for these.
Chair:
Chief Executive:
Immediate changes
Sharing the learning
Ensure risk assessments are completed for patients going
on leave, which identify risks in the community and
agreed actions to be taken by staff in case of a
breakdown in a plan.
To be shared with ward staff and community teams
We had proposed to take this report and learning to the Medical Advisory Committee Meeting
(MAC), however, due to the recent COVID activity this has not yet been possible. I can confirm
that the learning from the review has been shared with all of our Medical Staff and the
members of the MAC, it will also be added for further discussing at the next available meeting.
The learning from the review has been shared with our Senior Nurse Managers for sharing
within their teams and will be taken to our Senior Nurse Forum for discussion.
The report and learning was shared at the Eastern Locality Learning from Experience meeting
and the Adult Directorate Governance Board meeting in September.
Additionally,
, Deputy Medical Director is taking the learning to our Clinical
Advisory Group which is a senior clinical forum for further discussion including our Safe from
Suicide team with a particular focus on leave contingency plans and any other learning from
the review.
I would like to note that following further contact from Benjamin’s family we are currently
reviewing their detailed feedback which we anticipate will identify further areas of potential
learning and action for the trust. Any actions resulting from this work will be included in the
original action plan.
I understand from our team that we were not informed of the inquest taking place so we were
not able to attend and provide this assurance as we would normally have expected. I would
like to assure you that we would always be very happy to attend whether a ‘face to face’
attendance or virtual given the current Covid arrangements.
I hope that the actions described demonstrate our commitment to the learning we have
undertaken and that the Trust is committed to this continued positive work within our services.
If you require any further information please do not hesitate to contact me.
Yours sincerely
Chief Executive
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