Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2021-0063, written 4 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 | 4 Mar 2021 |
|---|---|
| Reference | 2021-0063 |
| Deceased | Grazyna Walczak |
| Coroner | Mary Hassell |
| Coroner area | Inner North London |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths · Mental Health related deaths · Suicide (from 2015) |
| Organisation named | Camden and Islington 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.
Regulation 28: Prevention of Future Deaths report
Grazyna WALCZAK (died 26.09.20)
THIS REPORT IS BEING SENT TO:
1.
Chief Executive
Camden & Islington NHS Foundation Trust (C&I)
4th Floor, East Wing
St Pancras Hospital
4 St Pancras Way
London NW1 0PE
1
CORONER
I am: Coroner ME Hassell
Senior Coroner
Inner North London
St Pancras Coroner’s Court
Camley Street
London N1C 4PP
2
CORONER’S LEGAL POWERS
I make this report under the Coroners and Justice Act 2009,
paragraph 7, Schedule 5, and
The Coroners (Investigations) Regulations 2013,
regulations 28 and 29.
3
INVESTIGATION and INQUEST
On 14 October 2020, one of my assistant coroners, Edwin Buckett,
commenced an investigation into the death of Grazyna Walczak, aged
61 years.
The investigation concluded at the end of the inquest earlier today. I
made a determination at inquest of death by suicide.
4
CIRCUMSTANCES OF THE DEATH
Grazyna Walczak jumped three storeys from her flat on 25 or 26
September 2020. She was suffering an acute depressive illness.
1
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.
1. Ms Walczak was seen by a psychological wellbeing practitioner
from the Camden and Islington iCope service two or three days
before her death. She was assessed as being at low to moderate
risk to herself.
However, she was not asked if she would agree to her family
being notified of the situation and of her current mental ill health.
Her son would dearly like to have been told what was happening
and would have acted accordingly.
I heard evidence that iCope does not routinely ask their patients
if families may be involved. This seems to be a policy worthy of
reconsideration.
2. The 72 hour investigation report that should be produced within
72 hours of death, to enable fast learning that may be of
immediate benefit to other patients, was not completed until last
week, some five months after Ms Walczak’s death.
That is obviously not acceptable and could put others at risk by a
potential failure to learn.
6
ACTION SHOULD BE TAKEN
In my opinion, action should be taken to prevent future deaths and I
believe that you 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 4 May 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.
2
8
COPIES and PUBLICATION
I have sent a copy of my report to the following.
Dr
HHJ Thomas Teague QC, the Chief Coroner of England & Wales
son of Grazyna Walczak
, team leader, iCope
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
DATE SIGNED BY SENIOR CORONER
04.03.21 ME Hassell
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.
4th May 2021 Private and Confidential Senior Coroner ME Hassell Inner North London St Pancras Coroner’s Court Camley Street N1C 4PP Dear Coroner Hassell Executive Office 4th Floor, East Wing St Pancras Hospital 4 St Pancras Way London NW1 0PE Tel: www.candi.nhs.uk Re: Inquest into the death of Grazyna Walczak – Prevention of Future Deaths report I am writing further to the inquest for Grazyna Walczak which was heard on 4th March 2021. Following the inquest, you issued a Prevention of Future Deaths report and I will address the matters of concern raised in this report in turn. 1. Ms Walczak was seen by a psychological wellbeing practitioner from the Camden and Islington iCope service two or three days before her death. She was assessed as being at low to moderate risk to herself. However, she was not asked if she would agree to her family being notified of the situation and of her current mental ill health. Her son would dearly like to have been told what was happening and would have acted accordingly. I heard evidence that iCope does not routinely ask their patients if families may be involved. This seems to be a policy worthy of reconsideration. The iCope service has reviewed the policy on contact with clients’ families in light of the PFD report. Up to now the service has not routinely collected information on ‘Next of Kin’ and would contact the person’s GP if that information was needed. iCope does, however, quite often involve relatives or partners in aspects of treatment if appropriate and with the consent of the patient. The service takes the confidentiality of its patients very seriously, so would not want to make it mandatory for people to give NOK information in order to access the service. However, in an emergency situation, where it might be necessary to contact someone very quickly, it would be prudent for the service to have that information available without having to go via the GP (which could cause a delay). The service has therefore agreed and implemented routinely asking for emergency contact details for all the people it sees, if they choose to share this information. It will be made clear that this information (an emergency contact name and telephone number) would only be used in emergency situations. The information will be recorded on the electronic case record so would be easily accessible to staff if it was needed (for example if someone became physically unwell during a session or we were very worried about risk and unable to get hold of the patient). 2. The 72 hour investigation report that should be produced within 72 hours of death, to enable fast learning that may be of immediate benefit to other patients, was not completed until last week, some five months after Ms Walczak’s death. That is obviously not acceptable and could put others at risk by a potential failure to learn. The Trust recognises that delays in the reporting process represent a delay in learning and the opportunity to continuously improve patient safety when incidents occur. This Trust has undertaken a review of the timeliness of 72-hour reporting to ensure adherence to meeting the requirements of the National SI Framework and to implement improvements in light of the prevention of future deaths report. This will ensure more timely reporting and organisational learning takes place. A review of the data of returned 72-hr reports within the Trust has found that reports are not returned within the 72-hr timeframe and as a result a programme of work has been started to address this. The following key recommendations were made and are being implemented 1. To undertake improvements in the 72-hour report submission process utilising quality improvement methods and monitoring and reporting progress through the existing reporting arrangements. 2. To formulate 72 hour reporting process maps for users to increase compliance and improved reporting quality. 3. To implement 72-hour reporting through the Datix patient safety incident reporting system to make reporting easier for the front- line staff. 4. To prepare a training package to enable implementation of reporting through Datix 5. To commence the training in the divisions 6. To evaluate the training package with the divisions after 3 months. 7. To monitor the programme of work through the Executive led Serious Incident Trust Forum and the Quality and Safety Programme Board 72-hour reporting: Programme of Work This programme of work has started and will take place over the next 4 months with an evaluation of progress at the 4-month stage and further improvements will be initiated, if required after that. The programme of work will be monitored through executive led meetings. Date April 2021 April 2021 May - June 2021 June 2021 Action Review of 72-hour reporting: Trust wide review of the 72-hour reporting process and analysis of data. Presentation of the review to trust and divisional colleagues to agree action and next steps to enable programme of improvement work to commence. Implementation of the reporting of 72-hour reports through the patient safety reporting system (Datix) to enable easier reporting. Implementation of a training programme for divisional staff to support the implementation of the new system reporting process. Monitoring arrangements Progress/Completion April 2021 April 2021 May - June 2021 April 2021 Weekly monitoring of compliance with 72-hour Continuous May 2021 April 2021 June 2021 July 2021 reporting. Review of the monitoring of compliance with 72-hour reporting through the serious incident forum chaired by the Executive Director of nursing. Review of the monitoring of compliance with 72-hour reporting through the serious incident forum chaired by the Executive Director of nursing and attended by the Executive Medical Director and the Divisional Directors and Clinical Directors. Evaluation Evaluation: Review of the new process and effectiveness of training. Progress report to the Quality and Safety Programme Board 72-hour reporting compliance. Continuous Continuous June 2021 July 2021 The programme of work will be undertaken, in collaboration with the divisions, to ensure there is a clear understanding of the process, roles and responsibilities of all those involved in the process. The Trust is committed to continuously improving systematic learning at the earliest opportunity by ensuring the timely submission of 72 -hour reports. I hope that my response clarifies the position and provides you with the necessary reassurance. If you need any further information, please do not hesitate to contact me. Yours sincerely Deputy Chief Executive (Signed on behalf of Camden and Islington NHS Foundation Trust , Chief Executive)
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