Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2021-0117, written 21 Apr 2021. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 21 Apr 2021 |
|---|---|
| Reference | 2021-0117 |
| Deceased | Mary Gwanyama |
| Coroner | Caroline Topping |
| Coroner area | Surrey |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths · Mental Health related deaths · Community health care · Railway related deaths · Suicide (from 2015) |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
IN THE SURREY CORONER’S COURT IN THE MATTER OF: MARY NABILIA GWANYAMA __________________________________________________________ The Inquest Touching the Death of MARY NABILIA GWANYAMA A Regulation 28 Report – Action to Prevent Future Deaths __________________________________________________________ • , Chief Executive Surrey and Borders Partnership 1 CORONER Caroline Topping HM Assistant Coroner, for the County of Surrey 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 An inquest into the death of Mary Nabila Gwanyama was opened on 1st June 2018, resumed on the 18th January 2021 and concluded on 10th February 2021. I found that the cause of death was: I a Multiple Injuries I concluded with a narrative conclusion as follows: Mary Gwanyama was admitted to the Abraham Cowley Unit as an informal patient on the 24th February 2018. She was suffering from severe depression. She was prematurely discharged on the 28th March 2018 to the home treatment team without a formal or adequate risk assessment having been undertaken, before it had been possible to assess whether her prescribed medications were effective and having been misdiagnosed immediately prior to discharge. She was not subject to medical review thereafter. On the 24th April 2018 she was discharged to the community mental health team. She was housed out of area in temporary accommodation which made it difficult for her to be visited by her care co- ordinator who did not see her in the 35 days prior to her death. On the 26th May 2018 she stepped down into the path of an oncoming train at Weybridge Station and was killed on impact. She intended to take her own life. Her death was therefore a result of suicide. I adjourned consideration of whether to write a report for the prevention of future deaths for further evidence to be provided by the 24th March 2021. 4 CIRCUMSTANCES OF THE DEATH i.) Mary held a British passport but had lived in America for a long period prior to coming to England in the autumn of 2017. She lived temporarily with her sister in Surrey. She was suffering from severe depression and was admitted to the Abraham Cowley Unit as an informal patient on the 24th February 2018. She was prescribed citalopram. ii.) She wanted to be rehoused in Surrey near her sister. As part of the discharge planning she was referred to Elmbridge Borough Council housing department who needed to undertake investigations to determine if she was eligible for housing. iii.) Mary was an experienced nurse and repeatedly said that the medication prescribed to her was not working. A date was fixed for her discharge from hospital. She did not want to be discharged. She feared being homeless. On the 21st March 2018 she expressed active suicidal thoughts and was placed on 1 to 1 nursing. iv.) On the 22nd March 2018 she was seen by her Responsible Clinician. Her medication was increased, her nursing observations were reduced to every 15 minutes and the discharge planned for the 26th March 2018 was moved to the 27th March 2018 to allow her to see the citizens advice bureau. The plan was for her to be discharged to the Home Treatment Team. v.) At that stage it had not been possible for the housing authority to determine if she was eligible for housing. Her care co-ordinator was not involved in the decision. No discharge planning meeting took place. vi.) On the 27th March 2018 she saw a member of the Home Treatment Team and expressed suicidal plans and refused Home Treatment Team involvement. She continued to say that the medication wasn’t working. Her discharge was delayed until the following day. vii.) On the 28th March 2018 she agreed to work with the Home Treatment Team because she was reassured that she could have a medical review in the community. viii.) She was then seen in a ward round and her diagnosis was erroneously changed to probable mild depression with emotionally unstable personality disorder traits. ix.) The discharge plan was for her to be housed at the expense of the Unit for 7 days at a Travel Lodge. There was no certainty at that stage that she would be eligible for housing after that date. The plan was that she was to attend the housing authority as homeless at the end of that period. She was discharged on that basis. x.) No risk assessment was recorded on the 22nd March 2018 or the 28th March 2018 after the medical reviews and no formal risk assessments were undertaken. xi.) Mary was under the care of the Home Treatment Team from the 28th March 2018 to the 24th April 2018. On the 30th March 2018 she stopped taking medication and expressed suicidal ideation. Her case was discussed at the multidisciplinary team meetings on the 3rd April 2018 and the 17th April 2018 which include junior doctors. It was unclear which consultant psychiatrist was responsible for her care at that time. xii.) Despite a request by one of the junior doctors to change her medication on the 17th April 2018 this was refused by one of the psychiatrists at the Abraham Cowley Unit. Mary was not medically reviewed prior to this decision being taken. xiii.) Payment for the Travel Lodge was extended until the 7th April 2021. It was still unclear at that stage if she was eligible for housing so she returned to her sister’s home until the matter was resolved. xiv.) Mary was found eligible for housing and given temporary housing out of area in Feltham on the 19th April 2020. The Home Treatment Team discharged her to the community team on the 24th April 2018. There was no discharge planning meeting with the care co-ordinator. The Care Programme Approach was not followed. xv.) Mary was seen on the 24th April 2018 by her care co-ordinator, he took an emergency supply of her medication with him. She sought a medical review and it was requested by the care coordinator on the 1st May 2018. xvi.) Mary was not seen for a medical review prior to her death on the 26th May 2018. She did not organise or collect a repeat prescription of her medication from the general practitioner in Surrey so would have been without medication prior to her death. Her care coordinator did not see her for 35 days before she died. xvii.) On the 26th May 2018 she stepped out in front on an oncoming train at Weybridge Station and died from the catastrophic injuries she sustained. 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. Mary was discharged from the Abraham Cowley Unit without a discharge planning meeting taking place in circumstances where there was no confirmation that she was eligible for housing provision and with no plan was to what would happen after the Travel Lodge placement ended. There is no policy in place which prevents a vulnerable patient being discharged into homelessness from the Abraham Cowley Unit. 2. Mary was not subject to a medical review from the 28th March 2018 to the 26th May 2018. There is no policy in place which mandates when or if a patient should be subject to face to face review by a consultant psychiatrist after discharge from the acute unit. 3. No formal risk assessment was undertaken of Mary and no risk assessment was recorded in her records prior to her discharge from the Abraham Cowley Unit. 4. The informal risk assessments undertaken in the Abraham Cowley Unit prior to her discharge failed to place any weight on the impact on Mary of a discharge with an inchoate plan for her housing and arrived at an incorrect assessment of her risk. The risk assessments were not sufficiently rigorous and evidence based. 5. Mary was prematurely discharged from the Abraham Cowley Unit suffering from severe depression and before sufficient time had been taken to observe the effectiveness of her prescribed medication. This appears in part to have been because the imperative to discharge patients took precedence over adequate discharge planning and assessment. The CPA ( “ Care Programme Approach”) was not followed. 6. Mary was discharged from the Home Treatment team on ineffective medication and without any coherent plan for her care in the community. Her care coordinator was not involved in the discharge planning. The CPA was not followed. 7. The fact that she was placed out of area made it difficult for her to participate in community based treatment and significantly impacted on the ability of her care coordinator and community psychiatrist to support her. There is no policy which governs how often a patient should be seen once in the community in order to review the risk assessment and monitor compliance with medication. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe your organisation has 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 16th 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. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons; and Elmbridge Borough Council. 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 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 Signed: Caroline Topping Dated this 21st April 2021.
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.
16 June 2021
Chief Executive’s Office
3rd Floor
Leatherhead House
Station Road
Leatherhead
Surrey
KT22 7ET
Dear Ms Topping
Inquest touching the death of Mary Gwanyama
Regulation 28 Report to Prevent Future Deaths (PFD)
Surrey and Borders Partnership NHS Foundation Trust’s Response
I am writing in response to your Regulation 28 Report to Prevent Future Deaths, hereafter
referred to as the ‘PFD’, issued on the 21st April 2021 following the inquest touching upon
the death of Mary Gwanyama. I would like to thank you for investigating this matter so
thoroughly and for bringing the matters of concern you have to my attention.
In the PFD, you identified five key areas of concern that had arisen from the inquest. I will
address each one in turn below, with details of action we have taken or plan to take to
address the issues.
1. Discharge planning and homeless patients
In the PFD, you said that Ms Gwanyama was discharged from the Abraham Cowley
Unit without a discharge planning meeting taking place in circumstances where there
was no confirmation that she was eligible for housing provision and with no plan as
to what would happen after the Travel Lodge placement ended. You identified that
there is no policy in place which prevents a vulnerable patient being discharged into
homelessness from the Abraham Cowley Unit.
The Trust accepts that a discharge CPA meeting was not held prior to Ms Gwanyama
being discharged from the Abraham Cowley Unit and, given she was homeless at the
time and her housing situation was uncertain, such a meeting should have taken
place. Accordingly, the Trust’s CPA policy and Acute Care Services Operational
Protocol will be updated to reflect that anyone who is homeless must have a CPA
discharge meeting on the inpatient ward prior to discharge.
Whilst we fully appreciate your concerns about no policy being in place, it is
unfortunately not possible for the Trust to have a policy in place that prevents patients
from being discharged into homelessness from our inpatient units. The onus is our
duty to engage appropriately with and make the statutory referral to District and
Borough Councils’ Housing Departments to find a homeless person settled
accommodation. The pre-discharge planning would also involve our homelessness
‘Duty to Refer’ to the District and Borough Housing Departments to include them in
the discharge CPA meeting. The discharge CPA meeting must be attended by all
the relevant professionals in a multi-agency approach.
2. Medical reviews
In the PFD, you said that Ms Gwanyama was not subject to a medical review from
the 28th March 2018 to the 26th May 2018 and that there is no policy in place which
mandates when or if a patient should be subject to face to face review by a Consultant
Psychiatrist after discharge from the acute unit.
Senior clinicians within the Trust have considered this issue, and our need to be agile
to respond to people with differing needs. For that reason, the decision as to whether
a person under HTT requires a medical review is risk and needs led within the context
of a multi-disciplinary approach which includes a Consultant Psychiatrist. (It should
however be noted that it is already mandated that a patient must have follow up with
community services within 72 hours of discharge from hospital, within an overall multi-
disciplinary approach.)
letter dated 24th March 2021, consideration is given at
As explained in
the daily HTT handover meetings, where there is a doctor present, as to how to best
meet people’s needs within their overall care plan. It should also be noted that in
addition to the handover meetings, each HTT holds weekly clinical reviews attended
by the full multi-disciplinary team. During this review, each person on the HTT
caseload is systematically reviewed to determine the appropriateness of the existing
care plan, risk management plans including medical review and discharge plans.
To strengthen our approach to risk assessments and risk management, our HTT is
now also going to use the SBAR (Situation, Background, Assessment and
Recommendations) which will support evidence-based multi-disciplinary review. The
HTT Operational Policy will be updated to reflect this and strengthen the
documentation and decision making regarding medical reviews.
3. Risk assessments
In the PFD, you said that no formal risk assessment was undertaken of Ms
Gwanyama and no risk assessment was recorded in her records prior to her
discharge from the Abraham Cowley Unit. Further, that the informal risk assessments
undertaken in the Abraham Cowley Unit prior to her discharge failed to place any
weight on the impact on Ms Gwanyama of a discharge with an inchoate plan for her
housing and arrived at an incorrect assessment of her risk. The risk assessments
were not sufficiently rigorous, and evidence based.
letter dated 24th March 2021, he outlined the significant improvements
In
that have been made regarding risk assessments since Ms Gwanyama’s death. In
particular, he highlighted that a new risk assessment node has been developed on
SystmOne, which was rolled out in October 2019 together with a training package
focussed on:
a.
Understanding risk assessment,
2
b.
c.
d.
e.
Understanding risk factors (dynamic and static),
How to make the best risk assessment,
The link between risk assessment and care plans, and
How to understand SystmOne’s new risk assessment tool.
In addition to this, in April 2021 we recruited a Lead Nurse for Quality and Practice,
specifically for inpatient services. Part of her role is around ensuring the quality of our
inpatient care plans and risk assessments and identifying areas for improvement. We
have also delivered a significant amount of Suicide Prevention Training across our
clinical services.
Weekly audits of risk assessments and care plans are conducted by Senior Matrons
in ACU and Farnham Road Hospital. We also have in place a discharge checklist, to
include whether a risk assessment has been completed prior to discharge. These
checklists have been in place for some time; however, they are not routinely audited.
We are therefore going to add to the weekly audits a review of the discharge checklist,
to ensure they are being completed appropriately and the learning loop closed.
We are also reviewing our Risk Assessment and Management Policy to support and
guide our staff in how to be confident in risk assessments risk and management.
4. Premature discharge
In the PFD, you said that Ms Gwanyama was prematurely discharged from the
Abraham Cowley Unit suffering from severe depression and before sufficient the time
had been taken to observe the effectiveness of her prescribed medication. You said
this appeared in part to have been because the imperative to discharge patients took
precedence over adequate discharge planning and assessment. Further, that her
care coordinator was not involved in the discharge planning.
The Trust considers that this issue will also be addressed by the change in policy and
practice that will require a discharge CPA meeting to take place prior to a homeless
person being discharged from the ward, with all the relevant professionals involved.
5. Community based treatment
In the PFD, you said the fact that Ms Gwanyama was placed out of area made it
difficult for her to participate in community based treatment and significantly impacted
on the ability of her care coordinator and community psychiatrist to support her. You
said that there is no policy which governs how often a patient should be seen once in
the community to review the risk assessment and monitor compliance with
medication.
Since Ms Gwanyama’s death, our community teams have implemented the SBAR
process during their MDT reviews to RAG rate patients and determine how often they
should be seen in the community based on their assessed risk. People’s risk changes
and people will move through the different levels of risk-based contact. If a patient is
rated Red, this requires weekly contact. If a patient is rated Amber, this requires
fortnightly contacted. If a patient is rated Green, then the contact ranges from monthly
3
appointments to annual outpatient appointments – the level of contact to be
determined by the MDT.
Our CMHRS Operational Policy is going to be updated, with specific attention to the
‘transition’ process to another Trust. Our policy is going to ensure that, where a
patient is in transition to a neighbouring Trust, we will still provide face to face or
telephone/virtual contact as we would base this on the SBAR/RAG rating and
identified frequency of need, until the transfer process is complete. If the patient is
residing in an area which is relatively local to the team and easily accessible by travel,
then we would expect the team to travel to visit the patient if necessary.
Further, where a patient’s needs are considered urgent, then the CMHRS will be
guided to make a referral to the patient’s local HTT/Crisis service (as this does not
require a CPA transfer), to ensure their immediate care needs are met and risks
assessed and appropriately supported.
I attach the Trust’s action plan that has been devised, to monitor and track our improvement
work. The delivery of the plan will be monitored through our established Inpatient
Improvement Board, chaired by the Chief Operating Officer and Chief Nursing Officer.
Regular briefings will be made to myself, as Chief Executive and the Executive Directors.
On behalf of the Trust, I would like to offer our sincere condolences to Ms Gwanyama’s
family for their loss and hope that our actions outlined above assures you and them that we
have learnt and continue to learn from her death.
Yours sincerely
Chief Executive
Enc Letter dated 24th March 2021
Action plan
4
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