Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2021-0164, written 20 May 2021. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 20 May 2021 |
|---|---|
| Reference | 2021-0164 |
| Deceased | Neil Challinor-Mooney |
| Coroner | Nadia Persaud |
| Coroner area | East London |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths · Mental Health related deaths · Suicide (from 2015) |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
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MISS N PERSAUD HER MAJESTY’S CORONER EAST LONDON Walthamstow Coroner's _ Queens Road a ™ "i REGULATION 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. BE vedica Director, North East London Foundation Trust, Suite 1, Phoenix House, Christopher Martin Road, Basildon, Essex, $814 3EZ CORONER | am Nadia Persaud, Area Coroner for the Coroner Area of East London 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 INVESTIGATION and INQUEST On the 29" November 2018 | commenced an investigation into the death of Neil Challinor-Mooney, age 51 years. The investigation concluded at the end of the jury inquest on 12 May 2021. The conclusion of the inquest was that Neil died as a result of suicide contributed to by neglect. CIRCUMSTANCES OF THE DEATH Neil Challinor-Mooney suffered an acute relapse in his mental health in late October 2018. He required admission to hospital under the provisions of the Mental Health Act on the 1s November 2018. Shortly after his admission to hospital, his trainers were removed from him as part of risk management. There was no documentation around the removal of the trainers. At some point during the course of admission to hospital (1s November to 16 November 2018) Neil’s trainers were returned to him. There was no documentation as to when the trainers were returned or any documentation around risk assessment or risk management relating to the decision to return the trainers. On the 13t November 2018 Neil disclosed in a ward round that he was having suicidal thoughts and that he would use his shoe laces to hang himself. The risk assessment and risk management plan was not updated as a result of this disclosure. Neil repeated this disclosure to a junior psychologist on the 14" November 2018. The psychologist disclosed the suicidal ideation and the plan to the senior nursing team. An action was documented for Neil’s shoes to be removed, but this was never carried out. On the 16% November 2018 Neil was found suspended by the laces of his trainers. He was in an unconscious state. Sadly, he passed away at Queens Hospital on the 18" November 2018. 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. — The Inquest heard evidence that the Trust policy in relation to risk assessment and risk management is sufficiently clear, however the Court was not fully satisfied that the said policy had been fully embedded into practice. Anumber of nursing staff, including senior nursing staff, during the course of the admission, failed to follow the policy. Another concern arising during the course of the Inquest related to the integrity of the electronic records. The Inquest heard that medical records should be validated very shortly after being entered into the system. The Court saw evidence of multiple entries where there was a significant delay between original entry and validation. Amendments were made to the records after Neil had passed away, but these were not apparent on the records disclosed to the Court. An audit of the records had to be carried out before the amendments were exposed. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you 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 15 July 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 Challinor-Mooney, the CQC and to the local Director of Public Health. Iam 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. [DATE] 20 May 2021 ore W
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.
Trust Head Office CEME Centre West Wing Marsh Way Rainham RM13 8GX Tel: 0300 555 1200 Ext:64290 09 July 2021 PRIVATE AND CONFIDENTIAL Miss N Persaud Her Majesty’s Coroner East London Walthamstow Coroners Court Sent by email to: Nadia.Persaud@walthamforest.gov.uk; and @walthamforest.gov.uk Your Ref: NP/SC/109728 Our Ref: 701 Dear Miss Persaud Re: Inquest touching upon the death of Mr Neil Challinor- Mooney I refer to your letter dated 20 May 2021 and the Regulation 28 report, detailing your concerns in care provided by NELFT NHS Foundation Trust (‘NELFT’). We have taken the concerns expressed by you very seriously and agreed to take a number of actions in addition to the actions already taken in respect of learning from the very sad death of Mr Challinor- Mooney. We are very grateful to you for your invaluable contribution in improving patient care. Please find attached action plan detailing the Trust’s efforts to prevent future deaths and to improve the safety and quality of care provided by the Trust. I hope that the attached action plan conveys our commitment to continuously improve our services, however if you would like to discuss these actions further, please kindly feel free to contact my office on 0300 555 1201. Yours sincerely Chief Executive Chair: Chief Executive: www.nelft.nhs.uk Cc: NELFT Legal Team , CQC CCG Chair: Chief Executive: www.nelft.nhs.uk
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