Prevention of Future Deaths reports · 2020
Regulation 28 report to prevent future deaths, reference 2020-0290, written 17 Dec 2020. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 17 Dec 2020 |
|---|---|
| Reference | 2020-0290 |
| Deceased | Andrew Gibbins |
| Coroner | Jacqueline Devonish |
| Coroner area | Suffolk |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths · Mental Health related deaths · Suicide (from 2015) |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
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: 1. 2. 1 CORONER I am Jacqueline Devonish, area coroner, for the coroner area of Suffolk 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 6 March 2020 I commenced an investigation into the death of Andrew Gibbins, 54. The investigation concluded at the end of the inquest on 1 December 2020. The conclusion of the inquest was that he died from multiple skull and rib fracture with pneumohaemothorax due to a road traffic collision and that he had taken his own life. 4 CIRCUMSTANCES OF THE DEATH On 15.01.2020 Mr Gibbins who had a long history of mental health informal admissions ran into the path of a lorry on the A14 Westbound. Eye witnesses confirmed that his actions were deliberate. His injuries were incompatible with life. Recognition of Life Extinct (ROLE) at 20:50 hours. Mr Gibbins had been unescorted awaiting test results on Acute Assessment Unit (AAU). He had expressed to a security guard that he was feeling suicidal and that was why he was under Wedgewood unit. He appeared withdrawn but this information did not reach Wedgewood or the Staff Nurse. 5 CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving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 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) The Hospital Security Guard guided Andrew Gibbins back to AAU looking lost and confused (following a cigarette break) when in a general way saying that he was feeling suicidal and that that had been the reason why he was under the care of Wedgewood. There were no immediate concerns for him, but the Security Guard had been concerned enough to ask for the Wedgewood staff member escort when he returned to AAU. Andrew’s presentation had not been reported to any clinician at either AAU or Wedgwood. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you AND/OR 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 18 February 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 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 17 December 2020 Jacqueline Devonish
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.
Norfolk and Suffolk NHS Foundation Trust For the attention of: Trust Management Jacqueline Devonish Hellesdon Hospital HM Coroner \ Drayton High Road Beacon House ‘ Hellesdon Whitehouse Road Norwich Ipswich NR6 5BE IP1 5PB 18 March 2021 Dear Ms Devonish, The inquest of Andrew Gibbins Following the inquest of Mr Andrew Gibbins on 1° December 2020 you issued a Prevention of Future Deaths Regulation 28 Notice to NSFT and the West Suffolk Hospital. We were surprised to receive this due to confirmation at the inquest that no such notice would be issued to any of the parties involved however, we understand that on reflection you felt communication needed to be improved between the two hospitals. To this end | would like to reassure you that we have taken your concern seriously and have in place a regular interface meeting with the West Suffolk Hospital to date we have held five such meetings. These previously were informal however we have moved these to a formal footing with agreed actions and minutes for governance purposes. This meeting is attended by senior staff who are authorised to make decisions. and implement improvements, actions are tracked, and communication pathways have been strengthen as a result. | hope this provides you with the information you need to assure you that communication has improved between the two providers. Yours sincerely, Chief Executive iogether Chair: Marie Gabriel CBE Chief Executive: Jonathan Warren NG TOGSINeS Trust Headquarters: Hellesdon Hospital, Drayton High Road, Norwich NR6 5BE > fox beter menial heaiih Tel: 01603 421421 Fax: 01603 421341 www.nsft.nhs.uk " AL Ee Sy Bs, Work!
Jacqueline Devonish H M Coroner Coroners Service Beacon House White House Road Ipswich Suffolk IP1 5PB Dear Coroner Chief Executive’s Office West Suffolk NHS Foundation Trust Hardwick Lane Bury St Edmunds Suffolk IP33 2QZ 17 February 2021 Re: Andrew Gibbins Deceased – Regulation 28 (Prevention of Future Deaths) Thank you for your letter regarding the investigation into the death of Mr Andrew Gibbins. I have asked our Head of Patient Safety, Head of Deteriorating Patient and Head of Mental Health to address the matters of concern that you have over the actions in the joint action plan with the Norfolk and Suffolk Foundation Trust - the response is as follows; Recommendation Two - Cohesive working between both Trusts with particular regards to joint working and inter Trust protocols; The Trusts have commenced monthly meetings between the head of mental health and the lead nurse for NSFT’s West Suffolk Care Group to ensure cohesive working/trouble shooting and good communication. These meetings are minuted for action planning, service improvement and assurance purposes. The handover process has been reviewed and when a patient is transferred from NSFT to WSFT for a physical health intervention the SBAR documentation will be handed over to WSFT staff. This information will be incorporated into the WSFT risk assessment. This will be incorporated into the acute hospital mental health policy by 31 May 2021. Recommendation Three – Acute hospital to review the missing person’s policy; The acute hospital missing person’s policy has been reviewed in January 2021 and deemed fit for purpose - attached. Recommendation Four – Acute hospital and ambulance Trusts to review communication processes. We have reviewed our communication process with the Ambulance Trust who have informed us that they did pass the information to us (as would be normal process for them), but on this occasion it appears there was some miscommunication. It has been reinforced with the staff involved the importance of ensuring all information has been received and documented correctly. I hope that the above information and evidence provides you with a level of assurance in making your final decision and thank you for your consideration in this sad inquest. Yours sincerely Dr Chief Executive Enc. Missing Persons Policy
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