Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2021-0095, written 31 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 | 31 Mar 2021 |
|---|---|
| Reference | 2021-0095 |
| Deceased | Steven Costello |
| Coroner | Catharine Palmer |
| Coroner area | West Sussex |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths · Mental Health related deaths · Suicide (from 2015) |
| Organisation named | Brighton and Sussex University Hospitals NHS 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: REPORT TO PREVENT FUTURE DEATHS (1) NOTE: This from is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: 1 Brighton and Sussex University Hospitals NHS Trust Eastern Road Brighton BN2 5BE 1 CORONER I am Catharine Palmer Assistant Coroner for the coroner area of West Sussex 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 15th October 2019 an Assistant Coroner commenced an investigation into the death of Steven Charles Costello aged 47 years. The investigation concluded at the end of the inquest on March 19th 2021 The conclusion of the inquest was that: SUICIDE 4 CIRCUMSTANCES OF THE DEATH Mr Costello developed mental health issues in August 2019. His GP supported him and referred him to primary mental health services. He experienced side effects with some medication and at the time he died he was prescribed Mirtazipine. His mental health deteriorated further so he and his supportive parents attended the Princess Royal Hospital (PRH) A & E department, part of the then Brighton and Sussex University Hospitals NHS Trust (BSUH) at 20.59 on October 3rd 2019. He was triaged and then assessed by a doctor from the Mental Health Liaison Service provided by Sussex Partnership Foundation Trust (SPFT) at approximately 21.30. During the 90 minute assessment he confided confidentially to the doctor that he was suicidal and had a rope at home. She advised him to stay in the hospital for the night (where he felt safe) to be re-assessed the next morning by the mental health team. There was no bed available in the hospital, so he remained in A & E. The Inquest heard evidence that patients in A & E at PRH remain in the care of that department regardless of their health needs. Two sets of notes exist in A & E for patients with Mental Health issues: paper notes in A & E accessible to all staff and Carenotes for SPFT which are electronic and not accessible to PRH staff. The assessing doctor spoke to a nurse and advised the nurse of the plan for his care. No note was made in the paper notes of this plan. He had an unsettled night, there was confusion regarding administering medication so none was given and at approximately 6.15 am on October 4th he was noticed to be missing from A & E. CCTV showed him leaving the hospital. At just after 7.00 am Sussex Police were contacted with a request to conduct a welfare check at his home. After some confusion the check was carried out by officers who believed he was not there. Some short time after the police left, his father attended and found him hanging. The Inquest heard evidence that his paper notes should have been undated by PRH staff every 2-3 hours. They had been completed at initial triage at about 21.00 on 3rd October 2019 but nothing was added until after Mr Costello had left the department on October 4th Regulation 28 – After Inquest Document Template Updated 11/11/2020 2019. There was no record of his care during this period of time or any written evaluation of his health needs to see if his mental health was declining, improving or remaining stable. Accurate evaluation and review of patients in the department is regarded as vital where needs can change in a very short space of time. 5 CORONER’S CONCERNS During the course of the investigation my inquiries 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: (brief summary of matters of concern) (1) Patient notes in the Accident and Emergency Department at the Princess Royal In circumstances where a patient attends A & E at the PRH with a mental health concern they can be seen by a Senior Nurse Practitioner or a Doctor working for SPFT who assesses them; however patient care remains the responsibility of PRH. SPFT have reviewed their practice so that a contemporaneous note of their consultation is copied from Carenotes and placed in the A & E paper notes. Evidence from a PRH witness at the Inquest confirmed that Mr Costello’s paper notes should have been updated every 2-3 hours to provide an accurate account of how he was progressing. The witness indicated that the notes themselves which PRH staff use (paper notes) needed updating and reviewing. This had been done previously for the PRH but then discarded following review by a Senior Nurse at the A & E department at Royal Sussex County Hospital which is also run by the same Trust. It is requested that the Trust consider updating the A and E notes on both sites at the very earliest opportunity and to include note of the need to regularly update them in line with policies and that all staff in A & E receive training on the need to complete those notes regularly with emphasis on the importance of recognising the notes as a vital tool in recording and evaluating a patient’s condition. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) 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 22nd June 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. COPIES and PUBLICATION 8 I have sent a copy of my report to the Chief Coroner and to the following Interested Persons (parents) (brother) (brother) Sussex Police Sussex Partnership Foundation Trust Brighton and Sussex University Hospital NHS Trust Independent Office for Police Conduct 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. Regulation 28 – After Inquest Document Template Updated 11/11/2020 I may also send a copy of your response to any 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 by the Chief Coroner. 9 Dated: 31/03/2021 Catharine PALMER Assistant Coroner for West Sussex Coroners Service Regulation 28 – After Inquest Document Template Updated 11/11/2020
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.
28 April 2021 Our ref: Mrs Catherine Palmer Assistant Coroner West Sussex Coroner's Service County Record Office Orchard Street Chichester West Sussex PO19 1DD Dear Mrs Palmer The late Steven Charles Costello University Hospitals Sussex NHS Foundation Trust Level 6, Trust HQ Royal Sussex County Hospital Eastern Road Brighton BN2 5BE Tel: (Senior Executive Assistant) Thank you for your Regulation 28 report dated 31 March 2021 and for your letter addressed to . Firstly, I would like to convey my sincere condolences to Mr Costello’s family and friends. We have contacted Mr Costello’s mother with the offer of a meeting to discuss the learning from Mr Costello’s inquest and to offer our support, condolences and sympathies in person. As you know, we take every death extremely seriously and learning from inquests is a vital part of our ongoing improvements to patient safety in our hospitals. The following steps have been taken following the inquest into Mr Costello’s death: Work is underway to update our Emergency Department template documentation and the revised documentation will be adopted by all of our Emergency Departments in our newly merged Trust. The new documentation is called Emergency Department Adult Mental Health Triage. It includes good clear guidelines that have been designed to help our Emergency Department staff to assess the risk of self harm, suicide, and the risk of harm to others when a patient is admitted to an Acute Hospital Emergency Department and is suffering from a mental health illness. The new documentation has a number of prompting questions which require the staff member caring for the patient to answer and space clearly labelled to scribe the answer; these questions have been designed with the help of our local mental health Trust, Sussex Partnership NHS Foundation Trust as the experts in the care of patients who are suffering from mental health illness. The documentation is colour coded with red, amber and green tick boxes (traffic light system) for an effective way to identify and to make the level of the risk in relation to an individual patient clear to all the staff in the Emergency Department. They will quickly be able to identify the level of risk from the patient’s records. The new documentation then highlights the actions required depending on the level of risk identified, such as the frequency of observations required, advice on whether a patient should be specialed and the contact numbers to use if further support is required from the mental health team or the security team. The new documentation comes with an information chart to display on the wall in the Emergency Department with easy to read and easy to understand guidelines and a checklist to assist the Emergency Department staff, highlighting the important steps to consider and what to regularly reassess, such as whether the patient’s regular medications have been prescribed so that they are available and can be administered whilst the patient is in the Emergency Department. This approach uses the mental health SMART assessment tool. We will audit the use of the new documentation to ensure there is a sustained improvement. We also intend to introduce this system of assessment and documentation to our Children’s Emergency Department. We are in contact with Sussex Partnership NHS Foundation Trust so that their expertise in the care of mental health patients is incorporated into our acute hospitals’ systems of assessment and in order to provide extra support and training to all of our Emergency Department staff. For additional reassurance, we are also arranging a peer review to focus on patient experience in our Emergency Departments so that we have an independent view to enable continuous improvements in the service we provide to our patients and their relatives and carers whilst in the Emergency Department. To ensure the learning and improvements following Mr Costello’s inquest are Trust wide with senior oversight, we have discussed the learning at our Trust Mortality Review meeting, in our Safety Huddles, and the Patient Safety Group meeting. Our joint Chief Nurse recently visited the Emergency Department at the Princess Royal Hospital to meet the staff who were responsible for Mr Costello while he was there. team have taken this tragic event, and she is assured that there is good senior oversight in the department and she has also been assured of the learning that has taken place following Mr Costello’s death. The importance of good quality documentation, with regular updates in the records of patients suffering with mental health illnesses, while in our hospitals waiting for a mental health bed, has been emphasised in training to the teams. has confirmed how seriously the Our documentation was not good enough for which I apologise. Mr Costello’s nursing care records should have been updated every 2-3 hours to provide an accurate account of how he was and whether there were any changes which might have triggered a further mental health review. As set out above, I can assure you that the Emergency Department documentation has been updated so that it is consistent in its application across the newly merged Trust. Thank you for bringing your concerns to our attention, I hope this response provides you with assurance of the actions we have taken to ensure improvement. Again, my heartfelt condolences go to Mr Costello’s family. Yours sincerely Chief Medical Officer and Deputy Chief Executive Page 2 of 2
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