Prevention of Future Deaths reports · 2020

David Ball

Regulation 28 report to prevent future deaths, reference 2020-0251, written 24 Nov 2020. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report24 Nov 2020
Reference2020-0251
DeceasedDavid Ball
CoronerEmma Serrano
Coroner areaDerby and Derbyshire
CategorySuicide (from 2015) · Mental Health related deaths · Alcohol, drug and medication related deaths · Community health care
Sourcejudiciary.uk record · original PDF
Responses published2

The report

Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.

Derby &  Derbyshire Coroner's Area 

REGULATION  28:  REPORT TO PREVENT FUTURE DEATHS (1) 

REGULATION  28  REPORT TO  PREVENT FUTURE  DEATHS 

THIS  REPORT  IS  BEING SENT TO: 

1.  The Family of Mr David  Ball; 
2.  NHS England; 
3.  NHS Digital; and 
4.  The  Chief Coroner 

1 

CORONER 

I am  Emma Serrano, Assistant Coroner for Derby and Derbyshire Coroners 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. 

3 

INVESTIGATION and INQUEST 

On  3 July 2018 I commenced an  investigation into the death of David  BALL.  The investigation concluded 
at the end  of the inquest 18th April 2018. 

The  conclusion  of the inquest was a suicide conclusion  as  follows: 

"Suicide contributed to by a discharge care plan, put in  place on  his discharge from an  informal inpatient 
stay on  the Hartington Unit on  the 1 June 2018,  not being fully implemented by the community mental 
health teams" 

The  medical cause  of death was 

la) Methadone and  Venlafaxine misuse 
CIRCUMSTANCES  OF THE  DEATH 

4 

1.  Between the 12 March 2019 and the 1 June 2019  David  Ball  was a voluntary patient at the 
Hartington Unit, which is  a mental health unit.  This was  due to an  extensive mental health 
history including suicide by overdose attempts.  David  Ball  had  a history of depression, paranoia, 
delusions and hallucinations.  In addition, he had  a history of drugs misuse.  He had a past 
history of deliberate overdose attempts when distressed and suffering from delusions. 

2.  On  the 1 June 2019 he was  deemed fit for discharge.  His  discharge care plan dictated that he 

was allocated a Community Psychiatric Nurse,  he was visited by a Social  Worker 3 times per day 
and  he wold be supported by the Community. 

3.  He did not receive a Community Psychiatric Nurse,  he received 3 social worker visits per day 

until the 4 June, and  he has support bf the Community Mental Health Team.  He was admitted 
to Chesterfield Royal  Hospital from the 4 June 2019 to the 17 June 2019.  This was for unrelated 
matters.  From the 4 June, to the date of his passing on  the 30 June 2019 his discharge care plan 
was  not carried  out. 

4.  The issues identified at inquest were firstly, the assumption that a Community Psychiatric Nurse 
would be allocated to David  Ball.  This was incorrect and would be subject to a decision making 

 process.  The outcome of which was that he was  not allocated one.  Secondly, there was 
assumed  communication  with  the sending of an  email, with  no  process for ascertaining that it 
was received  or actioned.  Finally,  different health care departments have different patient care 
records and the departments did not communicate with one another.  Evidence was heard that 
healthcare professionals would have to rely on  professional .curiosity to ascertain  crucial 
information regarding their patients. 

5. 

It was  accepted that David  Ball did not get the help and support envisaged when the Discharge 
Care  Plan  from the Hartington Unit was drafted. 

6.  On  the 30 June 2019  David  Ball was found deceased at his home address  having taken amounts 

of methadone and venlafaxine not compatible with life.  He  did so  with the intention of taking 
his  own life after delusions and  paranoia presented. 

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.  Evidence emerged during the inquest of two areas of 
concern: 

Different health care departments have different patient care records and the departments did not 
communicate with one another.  Evidence was heard that healthcare professionals would have to rely on 
professional curiosity to ascertain crucial  information regarding their patients.  The examples used  within 
the Inquest of David  Ball  were that the Hospital, Social  Care and  Derbyshire Healthcare all  had  different 
patient care  records. 

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. 
YOUR  RESPONSE 

7 

You  are under a duty to respond to this report within 56  days of the date of this report, namely by 12 
January 2021.  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: 

1.  The  Family of Mr David  Ball; 

2.  NHS  England;  and 

3.  NHS  Digital. 

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  November 2020 

Signature~ '~ ,U  
Emma  Serrano Assistant Coroner Derby and  Derby~hire Coroners Area

Responses

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.

Response from NHS Digital (PDF)
INHS

Digital
1 Trevelyan Square

Boar Lane
Leeds LS1 6AE

FAO: Emma Serrano PF

Coroner's Court
Town Hall

Rose Hill
Chesterfield
S40 1LP

Our Ret

2™4 March 2021

Dear Miss Serrano,
Inquest into the death of Mr David Ball

| am writing in response to the Regulation 28 report received from HM Coroner dated 25
November 2020. This follows the investigation and inquest into the death of Mr David Ball,
who sadly died on 30 June 2019..| would like to express my sincerest condolences to Mr Ball's
family. We would also like to apologise for the lateness for the return of this letter due to
administrative issues.

NHS Digital is a non-departmental public body created by the Health and Social Care Act 2012
and is the national information and technology partner for the health and care system. We use
technology to support the NHS and social care.

You have asked in paragraph 5, if NHS Digital has any information that can explain why
“different health care departments have different patient records and the departments did not
communicate with one another.”

Organisations have arrangements and systems in place to keep and maintain patient records,
whether electronic or not, and organisations share these records in accordance with their
processes and procedures. ;

NHS Digital is not responsible for a// the systems that hold patient information. We do provide
and have responsibility for the Summary Care Record (‘SCR’). The SCR helps professionals
across care settings to access GP held information on GP prescribed medications, patient
allergies and adverse reactions (SCR core functionality), and clinicians in. urgent and
emergency care settings access key GP-held information for patients previously identified by
GPs as most likely to present in urgent and emergency care) (SCR with Additional
Information).

Information and technology www.digital.nhs.uk
for better health and care enquiries@nhsdigital.nhs.uk

INHS
Digital

The patient record of Mr Ball has been checked within the SCR system by the Personal
Demographic Service team at NHS Digital. It is confirmed that there was no duplicate record
for Mr Ball, and no anomalies were identified.

The SCR is populated by GPs in their respective medical practices. The SCR holds the
following GP information about the patient:

e the name, address, date of birth and NHS Number;

-e current medication;

e allergies and details of any previous bad reactions to medicines;
e details of long-term conditions;

e any Significant medical history; and

e specific communication needs.

However, whilst key notes and significant medical history may be included by the GP; the
Discharge Care Plan is not the kind of information that is held and shared within the summary
record.

We understand from the request that the discharge care plan was not followed, and this was
not recognised. This is an issue of health and social care coordination and management.

In this context, and also outside NHS Digital’s area of responsibility, it is worth noting that there
are numerous initiatives across the NHS ‘and social care to: introduce systems that enable
patient records to be shared and accessible between all health and care providers in a locality.
Such systems would be expected to improve the planning and provision of shared care, and
reduce the risk of miscommunication. These initiatives are at different levels of maturity, but
can be expected to become increasingly widely-used.

If HM Coroner requires any further clarification in relation to any point, please do not hesitate
to contact us and we can assist further.

Yours sincerely,

Caldicott Guardian and. Clinical Director
NHS Digital
Response from NHS England and NHS Improvement (PDF)
Ms Emma Serrano 
Assistant Coroner, Derby and Derbyshire Area 
St Katherine's House 
St Mary's Wharf 
Mansfield Road 
Derby 
DE1 3TQ       

                  Professor 
                 National Medical Director 
                                  Skipton House 
                               80 London Road 
                                           SE1 6LH 

18th  June 2021 

Dear Ms Serrano,  

Re: Regulation 28 Report to Prevent Future Deaths – David Ball  

Thank you for your Regulation 28 Report (from hereon, ‘report’) dated 24 November 
2020 concerning the death of David Ball on 1 June 2018. Firstly, I would like to 
express my deep condolences to Mr Ball’s family. Secondly, I am sorry that it has 
taken so long to respond to this report. 

The regulation 28 report concludes Mr Ball’s death was a result of Methadone and 
Venlafaxine misuse.  

Following the inquest you raised concerns in your report to NHS England and NHS 
Improvement (NHS E/I) that his death was contributed to by a discharge care plan, 
put in place on his discharge from an informal inpatient stay in the Hartington Unit 
on the 1st June 2018.  Your concerns suggest that the discharge plan was not fully 
implemented by the community mental health teams. You further highlighted 
concerns that different healthcare departments have different patient care records 
and that departments did not communicate with one another. You pointed out that 
professionals would have to rely on ‘professional curiosity’ in order to ascertain 
crucial information regarding their patients. Furthermore, the providers involved in 
the final days and weeks of this Mr Ball’s journey all had different care records 
which contributed to the communication challenges. 

We are deeply saddened by the tragic death of Mr Ball and have taken this matter 
extremely seriously, having reviewed separate Serious Incident reports and 
statements from all the providers involved in Mr Ball’s care. 

In addressing your concerns and considering any risks going forward my 
colleagues in the Midlands Region have undertaken a review of Mr Ball’s care and 
identified actions as follows: 

NHS England and NHS Improvement 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
     
 
 
 
                                      
                                                         
 
 -  Shared Care Record: a clear plan is in place to bring together a shared care 
record for Derby and Derbyshire that plans to address the problems where 
there are multiple healthcare providers involved in a person’s care.  This 
work is unlikely to be completed until 2024.  In the meantime, there are 
systems in place to facilitate shared care conversations which include a 
Mental Health Liaison Team who will share relevant details on request and 
where appropriate in line with data protection regulations and a Mental 
Health Risk Triage Assessment Form, in use at Chesterfield Royal Hospital 
(CRH).  This triage assessment form is designed to prompt the professional 
completing it to contact the Mental Health Liaison Team where a risk is 
identified.  In Mr Ball’s case, it is accepted that this system was impacted by 
him not providing any history of mental health concerns to the staff at CRH 
and denying being on any medication; 

-  Learning from Deaths: in the Midlands a Learning from Deaths Forum has 
been established which brings together Acute, Community and Mental 
Health Trusts as well as the Regional Medical Examiner.  A suitably 
anonymised case study of Mr Ball’s experience has been taken to this forum 
for consideration, shared awareness and learning.  It is accepted that 
“professional curiosity” or clinical judgement plays a major part in 
determining health risks and it is unlikely that a system can replace such 
decision-making which is supported by the significant training medical and 
nursing staff undertake to carry out their roles.  The Forum will be tasked 
with considering system improvements complimentary to the move to a 
Shared Care Record and any recommendations will be escalated nationally 
through NHS E/I’s Executive Quality Group and associated sub-group which 
considers learning and improvement from these matters. 

Thank you for bringing this important patient safety issue to our attention and 
please do not hesitate to contact us if you require any further information. 

Yours sincerely, 

Professor 
National Medical Director   
NHS England and NHS Improvement  

NHS England and NHS Improvement

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