Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2021-0059, written 3 Mar 2021. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 3 Mar 2021 |
|---|---|
| Reference | 2021-0059 |
| Deceased | Steven Stout |
| Coroner | Graeme Irvine |
| Coroner area | East London |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths · Mental Health related deaths · Suicide (from 2015) |
| Organisation named | North East London NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
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MISS N PERSAUD SENIOR CORONER EAST LONDON Walthamstow Coroner's Court, Queens Road Walthamstow, E17 8QP Telephone 020 8496 5000 Email coroners@walthamforest.gov.uk REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) Ref 7 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Ministerial Correspondence and Public Enquiries Unit Department of Health and Social Care, 39 Victoria Street. London, SW1H OEU Sent via email to} And, CEO, North East London NHS Foundation Trust. Trust Head Office, CEME Centre- West Wing, Marsh Way, Rainham, Essex, RM13 8GQ Sent via email to: 1 | CORONER | am Graeme Irvine, acting senior coroner, for the coroner area of East London 2 | CORONER’S LEGAL POWERS | 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.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www legislation.gov.uk/uksi/2013/1629/part/7/made 3 | INVESTIGATION and INQUEST On 26" November 2019 | commenced an investigation into the death of Steven Paul David Gary Stout age 40. The investigation concluded at the end of the inquest on2nd March 2021. The conclusion of the inquest a narrative conclusion: “Mr Steven Stout was detained by police on the morning of 14 October 2019 under section 136 of the Mental Health Act 1983. Mr Stout was intoxicated by alcohol and had cut both of his wrists. Following medical treatment for his injuries Mr Stout was assessed at the section 136 suite at hospital. Following a Mental Health Act assessment, Mr Stout was made subject to an order under section 2 of the Mental Health Act 1983. After a three-day delay Mr Stout was admitted to a mental health ward on 17 October 2019. On the ward Mr Stout is assessed by a consultant, it was determined that he ought to be discharged from the section two order with support in the community from the home treatment team. Mr Stout was discharged from the ward on 18 October 2019 without a referral to the home treatment team, accordingly he was not supported in the community by them. On 4 November 2019 Mr Stout was found unresponsive, suspended by his neck from a ligature. Despite the prompt attendance of emergency services, he could not be resuscitated and his life was pronounced extinct at 07:43 hours. Mr Stout had deliberately taken his own life. Although it is possible that home treatment team support in the community could have avoided this outcome, it cannot be said, on the balance of probability, that home treatment team intervention would have probably provided an opportunity to Save or preserve Mr Stout's life.” The medical cause of death was: 1a Suspension CIRCUMSTANCES OF THE DEATH See above narrative 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 failure of Turner Ward, Goodmayes hospital to accurately record and file important medical records including; decisions on discharge, risk assessments, and a crisis, relapse and contingency plan. 2. The failure of Turner Ward Goodmayes hospital to ensure the effective referral of a patient from the ward to the home treatment team within the community. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you [AND/OR your organisation] have the power to take such action. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 28" April 2021 |, 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. COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the following Interested Persons the family of Mr Stout, the CQC. | have also sent it —_— Director of Public Health who may find it useful or of interest. | 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. | may also send a copy of your response to any other person who | 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. 3" March 2021 /f\ ‘SIGNED BY CORONER! (NOS:
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.
From Nadine Dorries MP Minister of State for Patient Safety, Suicide Prevention and Mental Health 39 Victoria Street London SW1H 0EU 020 7210 4850 27 May 2021 Your Ref: G1/ sc/ 111761 Our Ref: PFD-1311422 Mr Graeme Irvine HM Acting Senior Coroner, East London Walthamstow Coroners Court Queens Road London E17 8QP Dear Mr Irvine Thank you for your letter of 3 March 2021 about the death of Steven Stout. I am replying as Minister with responsibility for mental health services and I am grateful for the additional time in which to do so. To begin, I would like to say how very saddened I was to read the circumstances of Mr Stout’s death and I would like to offer my most heartfelt sympathies to his family and loved ones. It is so desperately sad to lose a loved one and to do so in circumstances where there is concern about the care they received must be particularly devastating. We must do all we can to take learnings from Mr Stout’s death and, in light of your concerns, I expect the North East London NHS Foundation Trust to look carefully at the care provided to Mr Stout and to take the actions needed to improve the care of mentally-ill patients and prevent future deaths. It is important that NHS organisations keep accurate medical records from admission and discharge and ensure that they are accessible to those involved in an individual’s care as is appropriate. More generally, I would like to assure you that we continue to take action nationally to support people with severe mental illnesses and to prevent suicide and self-harm. The NHS Long Term Plan and NHS Mental Health Implementation Plan 2019/20 – 2023/24, commits to new and integrated models of care between crisis, acute, primary and community services. These new and integrated models aim to ensure that people with severe mental illnesses can access the right level of support, advice and guidance wherever they present in the system. This includes providing care and support for people with co-existing substance use needs. On 27 March 2021, we published our COVID-19 mental health and wellbeing recovery action plan, backed by £500million to support people’s mental health in 2021/22. £58million of this will be used to accelerate the roll-out of the community mental health framework to treat adults and older adults with serious mental illness, including. This includes bringing forward the expansion of integrated primary and secondary care for adults and older adults with serious mental illness; embedding mental health practitioner roles in Primary Care Networks across the country to better meet the needs of people living with severe mental illnesses in primary care; and, expanding peer support and non- clinical workforce to boost the capacity of community mental health services. The recovery action plan also includes £6million funding to boost support for specific suicide prevention work. £1million will bolster NHS England and NHS Improvement’s work on suicide prevention and £5million is being made available to support voluntary sector organisations that prevent suicide in the community. This extra funding is in addition to the £57million investment for suicide prevention through the NHS Long Term Plan between 2019/20 and 202324, which will see investment in all areas of the country to support local suicide prevention plans and establish suicide bereavement support services. I hope this response is helpful. Thank you for bringing these concerns to my attention. NADINE DORRIES MINISTER OF STATE FOR PATIENT SAFETY, SUICIDE PREVENTION AND MENTAL HEALTH
PRIVATE & CONFIDENTIAL Mr Graeme Irvine Area Coroner Waltham Forest Coroners Court Queens Road Walthamstow London E17 8QP Sent by email to: Graeme.Irvine@walthamforest.gov.uk and @walthamforest.gov.uk Your ref: G 1 / sc/111761 Our ref: 894 Dear Mr Irvine, Chief Executive Trust Head Office West Wing CEM E Centre Rainham Essex RM 13 8GQ 7 April 2021 Re: Inquest touching upon the death of Steven Paul Gary Stout I refer to your letter dated 3 March 2021 and the enclosed Regulation 28 report issued in respect of your concerns regarding record keeping and the referral to Home Treatment Team (HTT), from Turner Ward at Goodmayes Hospital. The Trust has taken into consideration concerns highlighted in the Regulation 28 report and agreed to take a number of actions to address your concerns. This includes: Provision of record keeping training to staff on Turner Ward to ensure that staff are reminded about the Trust’s expectations in respect of the record keeping. Development and implementation of a discharge checklist to ensure that the discharge procedure safeguards patients’ clinical needs more robustly and supports healthcare staff. Audits to monitor implementation of the discharge checklist. Update of the HTT Service Operational procedure to ensure that the patients are not discharged without HTT or ACAT assessment, in the cases where there is a suggestion that the patients may benefit from HTT service input. Update to Trust’s Clinical Handover of Care and Discharge Policy to ensure that the discharges take place more safely and effectively, and the referrals have been effectively completed to address the clinical needs of the patient as required. Please find enclosed Trust’s action plan for further detail. I wish to assure you that learning from incidents is a priority for the Trust and I am very grateful for your contribution to the improvement of our services, by way of raising your concerns to me. Chair: Chief Executive: www.nelft.nhs.u k I hope that the enclosed action plan provides reassurance to you that the Trust has taken this sad incident very seriously and that it reflects our commitment to improve care quality and patient safety. If you have any further queries, please contact my office on Yours sincerely, Chief Executive Officer Encs: Trust’s Action Plan Regulation 28 report Chair: Chief Executive: www.nelft.nhs.u k Chair: Chief Executive: www.nelft.nhs.u k
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