Prevention of Future Deaths reports · 2020
Regulation 28 report to prevent future deaths, reference 2020-0297, written 11 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 | 11 Dec 2020 |
|---|---|
| Reference | 2020-0297 |
| Deceased | Claire Lilley |
| Coroner | Dr Julian Morris |
| Coroner area | London Inner (South) |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths · Mental Health related deaths · Suicide (from 2015) |
| Organisation named | Oxleas 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.
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: 1. Pinewood Place, Kent, DA2 7WG , Chief Executive, Oxleas NHS Trust, Pinewood House 1 CORONER I am Dr Julian Morris, assistant coroner, for the coroner area of Inner London South 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 16.7.2019 I commenced an investigation into the death of CLAIRE LILLEY, aged 38. The investigation concluded at the end of the inquest on 30 November 2020. The conclusion of the inquest, before a jury, was a narrative conclusion which, in summary, was as follows: Claire’s medical cause of death was: 1a Hypoxic Brain Injury 1b Hanging. Claire died as a result of injuries sustained by hanging herself. While the main contributing factor leading to her hanging was her mental illness, on the ward, relevant information was diffuse and there was no central formulation of the most pertinent information relevant to risk. This became especially relevant when several members of ward staff were on leave and there was insufficient management cover to review risk. 4 CIRCUMSTANCES OF THE DEATH Claire was detained undersection 3 of the Mental Health Act and admitted to Avery Ward on 22 October 2018, via the Queen Elizabeth Hospital following a significant overdose. During her admission she was diagnosed with a severe depression with psychotic symptoms in November 2018 and an additional diagnosis of generalised anxiety disorder in January 2019. She commenced various stages of ward leave in 2018 from accompanied to unescorted Section 17 overnight leave to her home. The status of that home leave and the anxieties she felt on leave varied. Claire gave a report to ward staff that although there were 1 (Claire’s mother) considered difficult times, overall the outcome was positive. that certainly by the end of January/ early February 2019, those visits were not positive, resulting in increased anxiety for Claire. There was no direct contact or proactively sought feedback, by staff, certainly after the 6 February. On the 6th, anxious views of home leave. A review on the 6th would, in the opinion of the appointed expert, have assisted in assessing her and was a missed opportunity. It was also confirmed that Claire’s risk assessment was not discussed with no centralised document reviewing her risk – ‘no formulation of that risk’. attended the ward and fed back her increasingly and there was On 12 February, whilst on Section 17 overnight leave, Claire hung herself at home. She was found by her mother. Despite further measures, she sadly did not survive. 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) Individuals who are the subject of detainment under the Mental Health Act are risk assessed at numerous times. For those that are on Section 17 home leave, they are additionally assessed prior to leaving the ward on each occasion. In addition, risks are also reviewed on the regular multi-disciplinary ward rounds. (2) However, such assessments are not centralised in any one place – there is no central formulation. Reviews by any clinician would have to cover 3 or 4 different entries by way of example: the risk assessment page, the MDT notes, the psychology entries (although they, per se, do not enter risks assessments). (3) The Court’s expert confirmed that such a centralisation/ formulation (supported by the Route Cause Analysis report), would assist in reviewing an individual’s risk and allowing ward staff to see the wider input in one place. (4) Training has been implemented by the Trust to assist staff in formulating risk, a process that was in place at the time of Claire’s death. However, there is no central repository/formulation of the outcomes of those assessments. Different teams continue to use different tools; there is no stand-alone document. (5) Consideration should therefore be given to the creation of a centralised, formulated, risk document to be entered upon by all clinicians irrespective of their own speciality. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe the Oxleas NHS Foundation Trust 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, However, given the forthcoming Christmas and New Year Period, together with the increasing pressures of Covid-19 I set the return date of Monday 1 March 2021. This maty be extended upon request. 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. 2 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons (Claire’s mother). I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any other person who I believe may find it useful or of interest. 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. 9 11.12.2020 Dr Julian Morris 3
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.
Oxleas NHS Foundation Trust Pinewood House Pinewood Place Dartford Kent DA2 7WG 13 April 2021 Dr Julian Morris Assistant Coroner London Inner South Southward Coroners Court 1 Tennis Street London SE1 1YD Fax: 01322 625727 Website: www.oxleas.nhs.uk Dear Dr Morris Re: Regulation 28 response to Prevent Future Deaths (PFD) Report following the inquest into the death of Ms. Claire Lilley Thank you for your correspondence received on 3 March 2021, containing a regulation 28 report to Prevent Future Deaths (PFD) following the conclusion of the inquest into the death of Ms. Claire Lilley on 30 November 2020. This response is made on behalf of Oxleas NHS Foundation Trust with regard to the concerns you set out in the PFD report. The concerns were: (1) Individuals who are the subject of detainment under the Mental Health Act are risk assessed at numerous times. For those that are on Section 17 home leave, they are additionally assessed prior to leaving the ward on each occasion. In addition, risks are also reviewed on the regular multi-disciplinary ward rounds. (2) However, such assessments are not centralised in any one place — there is no central formulation. Reviews by any clinician would have to cover 3 or 4 different entries by way of example: the risk assessment page, the MDT notes, the psychology entries (although they, per se, do not enter risks assessments). (3) The Court’s expert confirmed that such a centralisation/ formulation (supported by the Route Cause Analysis report), would assist in reviewing an individual’s risk and allowing ward staff to see the wider input in one place. (4) Training has been implemented by the Trust to assist staff in formulating risk, a process that was in place at the time of Claire’s death. However, there is no central repository/formulation of the outcomes of those assessments. Different teams continue to use different tools; there is no stand-alone document. MINDFUL we ABoy, « EMPLOYER ESSE = oy . DQ (5) Consideration should therefore be given to the creation of a centralised, formulated, risk document to be entered upon by all clinicians irrespective of their own speciality. We have explored options for the creation of a centralised, formulated, risk document to be entered upon by all clinicians irrespective of the own speciality. We already have an established centralised document that all clinicians are expected to complete on the electronic health record, RiO, before multidisciplinary meetings (MDT). It is known as the MDT template. We also have a Risk Information section on RiO where risk assessments are all recorded in a Risk Assessment document. Two years ago we separated the MDT template and the Risk Assessment document. The rationale for this was so that all professionals could update the MDT template ahead of MDT meetings and that all professionals could take ownership of updating the Risk Assessment document at the point of risks changing. In practice the Risk Assessment tends to be updated predominantly by medics as part of the MDT review (but this is affected by system and organisational factors). The Risk Assessment document will now be the centralised document for all professionals to document all risks immediately. To support, a new mandatory section will be added to the Risk Assessment document in Rio. This section will be a formulation summary. This summary will then automatically pull through to show on the MDT template and the inpatient care plan. To further address your concerns we will be focusing on ensuring that the Risk Assessment document is optimised by ward teams and that the MDT template utilisation is improved for wider discussions of the picture of risks for an individual. We will as a result: 1. Reinforce that all professionals are responsible for taking ownership for updating the Risk Assessment document. This will address an over reliance by multi-professional teams (nurses, psychologists, occupational therapists etc) on Consultants to update the Risk Assessment document. This means that in addition to escalating risks to the Consultant that all professionals must document risks at the time they are identified. It means that all professionals will be constantly thinking about risks and updating the Risk Assessment document when things happen. This will give a much better and clearer picture of risk events rather than that which might be achieved a formulation alone. 2. Reinforce the use of the Multidisciplinary Team (MDT) template where all involved professionals are required to input their feedback ahead of an MDT meeting to include their actions about documented risks that they have identified and added to the Risk Assessment document. However this needs to remain separate to the Risk Assessment document as it is not realistic for the weekly MDT meeting to update, summarise and state what might improve or worsen the risk. Currently the MDT template is not being used as effectively as it could be in a meaningful way, evidenced by internal transfers and this is being addressed with teams to reduce the variation. 3. Emphasis will be put on seeking information and feedback from service users and their families and carers, especially after periods of leave. We will require this to be consistently recorded in the Carer’s view in the MDT template following periods of all leave. 4. Adecision will be made about the risk at every MDT meeting. The MDT meeting will record as an action, who present at the MDT is going to update the risk assessment for a service user and then ensure that it is done. The allocated clinician will update the RiO Risk Assessment and associate management plan in the care plan for every risk identified after the MDT so it captures what was discussed and agreed. 5. To facilitate this we will remove from the current Risk Management Policy that it is the Responsible Clinician responsibility to ensure that a clinical risk assessment and clinical risk management plan is made before the decision is taken to discharge a person or grant leave. Currently the expectation is that the primary nurse does this but it is not working effectively when the primary nurse is not in the ward round. By making it the responsibility of a professional allocated at the time of the MDT meeting, the expectation that this happens immediately after the MDT meeting will ensue that the Risk Assessment document and associate management plan in the Care Plan is updated contemporaneously. 6. If anything changes in the period between MDTs, as stated, all clinicians will be expected to exercise their individual responsibility to personally update the Risk Assessment. 7. The Clinical Risk Assessment and Management Policy will be updated to reflect these standards. 8. The Medical Director and Director of Nursing will write to all clinicians about these agreed standards. This will be further facilitated through a team approach to risk management led by the Matrons. To conclude, | am grateful for your report which has ensured that additional measures are instituted so lessons are learned from the death of Ms Lilley. Yours sincerely, _ Chief Executive
See every Prevention of Future Deaths report matching Oxleas 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.