Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2021-0169, written 28 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 | 28 May 2021 |
|---|---|
| Reference | 2021-0169 |
| Deceased | Kevin Fitton |
| Coroner | Veronica Hamilton-Deeley |
| Coroner area | City of Brighton and Hove |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths · Alcohol, drug and medication related deaths · Mental Health related deaths · Police related deaths · Community health care |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text recovered by OCR from a scanned PDF. OCR is imperfect: check anything you rely on against the source PDF. Reproduced verbatim, including the scan's own layout.
VERONICA HAMILTON-DEELEY DL, THE CORONER’S OFFICE LL.B. WOODVALE, LEWES ROAD Her Majesty’s Senior Coroner BRIGHTON for the City of Brighton & Hove BN2 3QB CORONERS SOCIETY OF ENGLAND AND WALES ANNEX A REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) NOTE: This form is to be used after an inquest. THIS REPORT IS BEING SENT TO: 1. Brighton & Hove Health and Adult Social Car_ii 2. Brighton and Hove CCG/Sussex NHS Commissioner’s 3. Brighton & Hove Director of Kosi 4. Brighton & Hove Safer Communities Team [nn 5. Sussex Police — Care o 1 CORONER | am Veronica HAMILTON-DEELEY, Senior Coroner, for the City of Brighton & Hove 2 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. 3 INVESTIGATION and INQUEST On 17 September 2019 | commenced an investigation into the death of KEVIN JOHN FITTON. The investigation concluded at the end of the inquest on 5 May 2021.The conclusion of the inquest was Drug related death/misadventure being myocardial infarction directly related to Spice use in circumstances where a failure to obtain an urgent echocardiogram on 12%" July 2019 represented a missed opportunity to diagnose left ventricular hypertrophy and treat Mr Fitton in the High Dependency Unit. If the correct diagnosis had been made and if fluids had been administered in a more controlled way the outcome may have been different. The ongoing use of spice arose against a background of several years of ineffective care and support for stroke induced acquired brain injury causing self-neglect. VERONICA HAMILTON-DEELEY DL, THE CORONER’S OFFICE Her Majesty’s Senior Coroner WOODVALE, LEWES ROAD BRIGHTON for the City of Brighton & Hove BN2 3QB CIRCUMSTANCES OF THE DEATH Kevin Fitton suffered a catastrophic stroke at the age of 33 in 2010. Prior to that he was a successful fit man enjoying his life in all respects. Following the stroke, although properly assessed by the leading neuropsychologist so that the damage was fully recognised, his ongoing care never reflected his needs. It was clear from the evidence that none of those providing that care understood the effects on him of his acquired brain injury. In particular during the nine plus years between the stroke and his death, Kevin’s mental capacity was only assessed on three occasions, the last being in 2013 at the insistence of one of his sisters. His last Care Act Assessment in 2017 was incomplete and not followed through. His care was branded ineffective by the Independent Safeguarding Adult Reviewer. The main problems were his self-neglect, his almost daily use, latterly, of Spice and his vulnerability which meant he was taken advantage of by some members of the street homeless community. His Spice use took him to Accident and Emergency on several occasions in the last two to three years of his life. The final admission was on 12t July 2019. Kevin required fluid support, however, the precarious state of his heart was not identified (a requested echocardiogram was not carried out). He became fluid overloaded, had a cardiac arrest and died some 27 hours after being brought into Hospital by ambulance. 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) There was an almost complete reliance of assumption of capacity. The lack of capacity assessments resulted in failure to identify the area and support needed by Mr Fitton and a failure to use best interests policy appropriately. (2) There was a failure to seek specialist support regarding Acquired Brain Injury (AB)). (3) There was a failure to understand the way Mr Fitton’s AB! impacted on his abilities. (4) There was a failure to understand how ABI impacted on Mr Fitton’s substance use and vice versa. (5) Communication between the various teams and individuals were poor. (6) Lead and Co-ordination were lacking. (7) There was a failure to react to the deterioration in Mr Fitton’s living conditions, his being cuckooed, the downward slide in his physical health and the increase in his drug use. (8) Staff received no adequate training in dealing with ABI. There was no training on the Codes of Practice for the Mental Capacity Act or the Care Act. | (9) There was a reasonable Care Act Assessment in 2017 however it was VERONICA HAMILTON-DEELEY DL, THE CORONER’S OFFICE LL.B. WOODVALE, LEWES ROAD Her Majesty’s Senior Coroner BRIGHTON for the City of Brighton & Hove BN2 3QB poorly/inadequately implemented. It should have been repeated annually ~ it was not. (10) There was a failure to deal with Mr Fitton’s situation robustly. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you AND 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 19" July 2021. 1, 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 | have sent a copy of my report to the Chief Coroner and to the following Interested Persons Chief Coroner Family of Mr Fitton University Hospitals Sussex NHS Foundation Trust Secretary of State for Health, Department of Health a chict Executive, NHS England er ...:. & Hove City Council | 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. NOaRWON> | 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 by the Chief Coroner. VERONICA HAMILTON-DEELEY DL, LL.B. Her Majesty’s Senior Coroner for the City of Brighton & Hove THE CORONER’S OFFICE WOODVALE, LEWES ROAD BRIGHTON BN2 3QB 9 Date: Wee May LIX Senior Coroner Brighton and Hove
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.
NHS Commissioners
Ms Veronica Hamilton-Deeley
The Coroner's Office Woodvale
Lewes Road
Brighton
BN2 3QB
ath September 2021
Dear Ms Hamilton-Deeley
Sussex NHS Commissioners
Hove Town Hall
Norton Road
Hove
BN33BQ
The late Kevin John Fitton - Prevention of Future Deaths Report
On 24th May, Brighton and Hove Clinical Commissioning Group, part of Sussex NHS
Commissioners, received
the Coroners
(Investigations) Regulations 2013.
the above report in accordance with
Sussex NHS commissioners have considered the report and discussed your concerns
both internally and with other Health and Social Care partners in Brighton and Hove
via the Safeguarding Adults Board.
As you will be aware, the Safeguarding Adults Board held a Safeguarding Adults
Review following the death of Mr Fitton. This review resulted in a number of
recommendations which were reflected in the Prevention of Future Deaths Report.
Having considered these actions the Safeguarding Adults Board has created an action
plan to ensure that those recommendations will be achieved. This plan will be regularly
monitored by the Safeguarding Adults Board to ensure progression at a reasonable
pace.
Within the plan the Clinical Commissioning Group is required to share the report with
commissioners so as to give consideration to how long term service delivery can be
improved for people with acquired brain injuries. The report has been shared with
commissioners who are reviewing how acquired brain injuries can be specifically
considered within the services that are commissioned.
The Clinical Commissioning Group will continue to engage with partner organisations
in the Safeguarding Adults Board to support service improvement for people with
acquired brain injuries.
Yours sincerely,
Chief Nursing Officer
On behalf of Sussex NHS Commissioners
NHS Brighton and Hove CCG
NHS East Sussex CCG
NHS West Sussex CCG
Brighton & Hove
City Council
Health and Adult Social Care
Brighton & Hove City
Council
Second Floor, Hove Town Hall
Norton Road
HOVE
BN33BQ
Private and Confidential
Veronica Hamilton-Deeley DL, L.L.B,
Her Majesty's Senior Coroner for the
City of Brighton & Hove
Date:
Ref::
14th July 2021
Dear Ms Hamilton-Deeley
Re: Inquest into the death of Kevin John Fitton on 04 May 2021
With respect to the above inquest thank you for sharing your formal Report to Prevent
Future Deaths made under Regulation 28 that I have read carefully and has been given
full consideration by myself and colleagues within the Health and Adult Social Care
directorate at Brighton and Hove City Council. Please find enclosed our formal response
in which we have fully acknowledged the areas you have raised with us. To support and
develop good practice we have progressed on a number of key actions as detailed within
our response.
Kind regards
Executive Director Health and Adult Social Care
Enc.
Executive Director Health & Adult Social Care
Web: www.brighton-hove.gov.uk
Printed on recycled, chlorine-free paper
Private and Confidential
Veronica Hamilton-Deeley DL, L.L.B,
Her Majesty's Senior Coroner for the City of Brighton & Hove
Dear Ms Hamilton-Deeley
Response to Report to Prevent Future Deaths made under Regulation 28 and 29 of the
Coroners (Investigations) Regulations 2013 concerning Kevin John Fitton
Thank you for your correspondence of 20th May, Regulation 28 report to prevent future
deaths, noting your concerns raised during the course of the inquest regarding Kevin John
Fitton.
We would like to acknowledge the areas you have noted and thank you for feeding back to
our organisation regarding these.
As you know a Safeguarding Adults Review (SAR) under S.44 of the Care Act 2014 has been
undertaken following concerns regarding whether agencies could have worked more
effectively to with Kevin Fitton.
With regard to the concerns you have raised with us at the Local Authority we provide the
following response. This response is based on meetings and conversations that have taken
place in the Local Authority since receiving your s28 regulation notice, involving key internal
stakeholders leaders and practitioners in our directorate, in order that we ensure we are
responding proactively and working together to address the concerns you raise.
We have fully considered each of your concerns, namely:
• There was an almost complete reliance on the assumption of capacity. The lack of
capacity assessments resulted in failure to identify the area and support needed by
Mr Fitton and a failure to use best interests policy appropriately
• There was a failure to seek specialist support regarding Acquired Brain Injury (ABI)
• There was a failure to understand the way Mr Fitton's ABI impacted on his abilities
• There was a failure to understand how ABI impacted on Mr Fitton's substance use
and vice versa.
• Communication between the various teams and individuals was poor.
•
Lead and Co-ordination were lacking
• There was a failure to react to the deterioration in Mr Fitton's living conditions, his
being cuckoo'd, the downward slide in his physical health and the increase in his
drug use.
• Staff received no adequate training in dealing with ABI. There was no training on the
codes of practice for the Mental Capacity Act or the Care Act.
• There was a reasonable Care Act assessment in 2017 however it was
poorly/inadequately implemented. It should have been repeated annually, it was
not.
• There was failure to deal with Mr Fitton's situation robustly.
In response we update you on the following which we are taking forward to support and
develop good practice in these areas:
• While there is existing training on trauma available within the Local Authority we are
actively considering the implementation of further specialised training on trauma,
namely the PIE model (psychologically informed environments) which other areas of
the Local Authority have found useful in terms of enhancing their systems and
processes to better enable access and understanding.
• We will take forward the area of Social Work practitioner access to specialists when
undertaking capacity assessments with people with new or historic ABI and/or when
the specific brain impairment necessitates a specialist. We will explore a joint
commissioning arrangement with health to agree a pathway for our health and adult
social care practitioners to access.
• We will review our existing Mental Capacity Act {In Practice) training which includes
the Code of Practice, and guidance on use of the Best Interests process and refresh
the message on ensuring good practice of this. We will monitor practitioner take up
of the training, percentage attended and those who have refreshed, and
communicate with front line teams to ensure practitioners attend these and refresh
regularly.
• We will review our Care Act training on offer and make any adjustments necessary to
ensure that the key aspect of co-ordination in multi-agency work, and consideration
of review, are refreshed features.
• We will ensure that our Safeguarding training contains additional focus on non
engagement in safeguarding adults responses to cover where this needs to be
provided creatively between partner agencies (for example, as was the case with Mr
Fitton, the person will not engage with the Local Authority Social Worker).
• We have designed and implemented a non-engagement policy within the directorate
which is now live.
• We will ensure that the SAR action plan and your concerns are included in our
Safeguarding Adults Governance, Quality Assurance and Performance groups
• We will develop a stand-alone training course on Mental Capacity Assessments and
executive functioning/capacity
• We will continue to provide standalone training courses on Acquired Brain Injury and
will encourage practitioner engagement in this training course as well as extending
the content depth and duration.
• We will continue to provide training on self-neglect which references SAR outcomes
and decision making
• We will continue to attend the police led multi agency cuckooing meeting and
encourage increased awareness of this within our directorate and we will seek
opportunities for wider learning from this meeting.
• We acknowledge the value of a specific expertise to support substance misuse
casework in Health and Adult Social Care and will continue to encourage awareness
and understanding of the importance of consulting relevant expert staff where
appropriate.
• We will share these responses with our health partners in commissioning of services
and specialist accommodation.
• We will provide monitoring and governance of these responses and actions through
our Practice Development and Assurance Board within the directorate.
• We will work with our partners to finalise the Sussex wide SAB escalation and
resolution policy which is being developed.
• We will review our internal risk management protocols for casework to strengthen
our organisational oversight.
• We will request that all Learning and Development consultants are enabled within
our Workforce Development Team to read SARs and ensure that lessons are
incorporated into relevant training
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