Prevention of Future Deaths reports · 2020
Regulation 28 report to prevent future deaths, reference 2021-0086, written 10 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 | 10 Dec 2020 |
|---|---|
| Reference | 2021-0086 |
| Deceased | Rory Attwood |
| Coroner | Caroline Saunders |
| Coroner area | Gwent |
| Category | Mental Health related deaths · Alcohol, drug and medication related deaths · Community health care · Suicide (from 2015) · Wales prevention of future deaths reports (2019 onwards) |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 REGULATION 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. (cid:9) Chief Executive, Aneurin Bevan University Health Board 1 CORONER I am Caroline Saunders, Senior Coroner for the Area of Gwent CORONER'S LEGAL POWERS 2 3 1 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 INVESTIGATION AND INQUEST On 11 /10/2018 an investigation was opened into the death of Rory Karl Attwood DOB 28/6/96 The investigation concluded at the end of the inquest on: 3/11/2020 The conclusion of the inquest was recorded as: Suicide The medical cause of death was: 1a) Acute Methylenedioxyamphetamine (MDMA) Toxicity 4 CIRCUMSTANCES OF THE DEATH Rory Attwood had a history of mental health problems. On 27 July 2018 Rory jumped from Union Street bridge in Newport, South Wales and injured his legs. He underwent a psychiatric assessment at which time he denied any suicidal attempt and that he had slipped when drunk. A further assessment revealed that whilst Rory had no obvious immediate suicidal intent, of concern was the fact that he showed no remorse for his actions. On 3111 August Rory discharged himself from hospital. He underwent a social care assessment at which time it was confirmed that Rory needed to he re- homes but there was no further involvement in Rory's care from the adult Disability team. Furthermore Rory was not followed up by community mental health teams. It is obvious that Rory was vulnerable and yet there was no statutory monitoring arranged because he did not fall squarely into a box of social, physical or mental health. Rory continued to ruminate over ending his life. At about 5am on 9/10/18. Rory's father entered his son's bedroom and discovered that Rory had died. Emergency services were called but Rory could not be revived and the paramedics confirmed his death at 05:25 hours. A post mortem examination concluded that Rory had suffered an acute cardiac event and that Rory had in his blood f MDMA normally consumed for recreational purposes. In the absence of any underlying cardiac pathology the pathologist's opinion was that the cardiac death has on balance been caused by the consumption of an excessive quantity of MDMA. Following the inquest an internal investigation was undertaken, by Aneurin Bevan University Health Board and recommendations were made in relation to more cohesive working practices between partner agencies. At the inquest Rory's General Practitioner, Dr gave evidence. He was asked about how practices had changed since Rory's death. Dr admitted that General Practitioners rarely (and he has never been) invited to participate in a Serious Untoward Incident Review when a community patient has died. 5 CORONER'S CONCERNS During the course of the inquest, 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: - The purpose of undertaking a Serious Untoward Incident Investigation, is to identify necessary organisational changes which can improve the outcomes for patients and hopefully prevent future deaths. Rory had been discharged from acute services and was under the care of his General Practitioner. In keeping with many people he had been involved with different arms of ABUHB (primary, acute and psychiatric) He had been involved with social services. After his death the charity MIND wrote to me and expressed concerns that Rory had fallen between gaps in services. This was addressed in the internal investigation undertaken by ABUHB, however it is surprising that his GP was not involved in this review and Dr investigations. e told me that GPs are rarely asked to participate in these In order that lessons can be learned and opportunities identified for better partnership working around patients, it would seem appropriate that the patient's (cid:9) primary care contact (especially when being supervised in the community) be involved in internal /serious incident reviews. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. I should be grateful if the following information be provided to me: Confirm whether it is your intention to review the current process of serious incident investigation and ensure that General Practitioners (and indeed any other relevant third party agencies) are to be routinely involved in serious incident reviews in the future. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely 6th February, 2021, I, the Coroner, may extend this 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 necessary 8 COPIES AND PUBLICATION I have sent a copy of my report to the Chief Coroner and the following Interested Person (s) • The father of Mr Rory Attwood • The mother of Mr Rory Attwood 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 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 DATE 10/12/2020 Signed Cj Caroline Saunders Her Majesty's Senior Coroner for the Area of Gwent.
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.
GIG NHS Bwrdd Iechyd Prifysgol Aneurin Bevan University Health Board y Our ref: P| Direct une 4 February 2021 Ms Caroline Saunders HM Senior Coroner for Gwent Room 204W The Civic Centre Godfrey Road Newport NP20 4UR Dear Ms Saunders Re: Regulation 28 Report received by Aneurin Bevan University Health Board further to the inquest touching on the death of Rory Attwood. Thank you for your report dated 10 December 2020, which was received by the Health Board on 15 December 2020. Further to your report, I am pleased to inform you that the Aneurin Bevan University Health Board has reviewed its practices with regard to GP involvement in Serious Incident Reviews. Furthermore, the Mental Health and Learning Disabilities Division has devised a process and pro forma to aid the timely sharing of pertinent information, and to ensure that GPs are routinely invited to participate in reviews of Serious Incidents. Copies of both documents are enclosed for your information. Whilst I must highlight that only a small number of GP Surgeries within the Gwent area are managed by the Health Board and the vast majority are managed independently, it is hoped that this process will enable the Health Board to engage with both managed and non-managed GP surgeries when conducting Serious Incident Reviews. The Mental Health and Learning Disabilities Division is reviewing its processes to ensure that involvement of third sector and other organisations is recorded sooner, thus ensuring that such organisations are also invited to participate when they have been involved in a person’s care. This invitation will be sent in letter format as opposed to the pro forma format described above. Pencadlys Headquarters Ysbyty Sant Cadog St Cadoc’s Hospital Ffordd Y Lodj Lodge Road Caerllion Caerleon Casnewydd Newport De Cymru NP1i8 3XQ th Wal 1 Fén: 01633 234234 South Wales NP18 3xQ Te! No: 01633 234234 Bwrdd lechyd Prifysgol Aneurin Bevan yw enw gweithredo!l Bwrdd lechyd Lleol Prifysgol Aneurin Bevan Aneurin Bevan University Health Board is the operational name of Aneurin Bevan University Local Health Board I trust that this information addresses the concerns raised in your report, however please do not hesitate to contact me should you require any further information. Yours sincerely Chief Executive/ Prif Weithredwr MENTAL HEALTH & LEARNING DISABILITIES DIVISION NOTIFICATION TO GP OF AN SUI REVIEW IN THE DIVISIO HE ead of Quality & improvement QPS Department, MH & LD Division Divisional Office St Cadoc’s Hospital Lodge Road, Caerleon, Newport. NP18 3XQ. _—————— GP address = Dear Dr xxxxx We have been notified recently of the death of a patient known to your practice. As an unexpected death, this meets the criteria for a Serious Untoward Incident within the Division and thus the Division will be reviewing this patient’s care from the Mental Health/ Learning Disability service. | would be grateful if you would kindly return this form to the above email address at your earliest convenience, answering the following: a) | attach pertinent information with regard to recent (last 6 months) Primary Care 7 . Tick to involvement indicate attached b) | would like to be included in the review of this patient’s care Yes No oO Oo Many thanks P| Head of Quality & Improvement INCIDENT REFERENCE NO. | iy ~ DETAILS OF PERSON Date of Birth Address MH SERVICE INFORMATION Team Consultant (if applicable) Last Contact OVERVIEW OF THE INCIDENT Date and time of incident Location of incident Brief Summary of incident Suspected Cause of Death (If known) MENTAL HEALTH & LEARNING DISABILITIES DIVISION PROCESS FOR NOTIFYING AND INCLUDING GP IN SERIOUS UNTOWARD INCIDENT REVIEWS IN THE DIVISION Following a recent Coroner’s Inquest into the death of aman who had previously been known to the Mental Health service, HM Senior Coroner wrote the Health Board on 10 December 2020 enclosing a Regulation 28 report. HM Coroner asks the Health Board whether it intends “to review the current process of serious incident in vestigation and ensure that General Practitioners (and indeed any other relevant third party agencies) are to be to be routinely involved in serious incident reviews in the future’. Background Within the MH & LD Division, the following incidents will trigger notification to Welsh Government/ Delivery Unit © Unexpected death or suspected suicide of any patient a) open to the secondary care mental health service b) open to the secondary care mental health service in the previous 12 months to include © Current in-patient (informal) © Current in-patient (detained) © Current patient of CRHTT © Unexpected death within 14 days of discharge from MH ward ‘Expected’ deaths if the patient is detained to a MH ward ° Unexpected death or suspected suicide of any patient known to PCMHSS, GSSMS, Learning Disability Service or Secondary Care Mental Health Service within the last 12 months © Suspected homicide Perpetrated by a patient open to a secondary care MH service e Any incident that staff or relatives identify as potentially having been contributed to by act or omission on behalf of the Health Board For most incidents, a concise review is completed by the team, collating the details of the person and the incident, and providing a chronology of events. This is then reviewed by a group of senior clinical staff from within the Division and the wider Health Board (e.g. Safeguarding, Legal Services etc) and decision made as to whether a Reviewing Officer should be appointed to complete a comprehensive review. The Division does not currently routinely request information or involvement from GP unless the terms of reference for review include this and/or the GP has been very much involved in the care. Where other agencies have been involved, such as the Local Authority Social Services and/or third sector/ independent providers, the Reviewing Officer would make contact with these organisations [ Recommendations 1. The MH & LD Division will use a pro forma to notify the GP of an unexpected death ofa patient in the Division. This will be sent by email from the Division’s.Quality and Patient Safety (QPS) department to the GP Practice. 2. The Pro Forma gives the patient details and a summary of the incident, and requests a brief copy of recent/ salient information from the GP. It also asks the GP to confirm whether they would like to be involved in the review. 3. The GP Practice then emails this pro forma back to the Division’s QPS department. It is suggested that this process is tried for 6 months; following which, the MH & LD Division will liaise with the Primary Care and Community Division to review the process and take forward any suggested amendments. Head of Quality & Improvement MH & LD Division 1.2.21 For review August 2021
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