Prevention of Future Deaths reports · 2020

Claire Lilley

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 report11 Dec 2020
Reference2020-0297
DeceasedClaire Lilley
CoronerDr Julian Morris
Coroner areaLondon Inner (South)
CategoryHospital Death (Clinical Procedures and medical management) related deaths · Mental Health related deaths · Suicide (from 2015)
Organisation namedOxleas NHS Foundation Trust
Sourcejudiciary.uk record · original PDF
Responses published1

The report

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

Responses

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.

Response from Oxleas NHS Foundation Trust (PDF)
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.

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(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

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