Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2021-0187, written 1 Jun 2021. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 1 Jun 2021 |
|---|---|
| Reference | 2021-0187 |
| Deceased | Kesia Waller |
| Coroner | Samantha Marsh |
| Coroner area | Hampshire, Portsmouth and Southampton |
| Category | Child Death (from 2015) · Care Home Health related deaths · Suicide (from 2015) |
| 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.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. A2Dominion of The Point, 37 North Wharf Road, London W2 1BD 1 | CORONER | am Samantha Marsh, Assistant Coroner, for the coroner area of Hampshire, Portsmouth and Southampton 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 the 27'" January 2020, | commenced an investigation into the death of Kesia Blaine Waller, aged 17. The investigation concluded at the end of the inquest on 20 May 2021. The conclusion of the inquest was cause of death: 1(a) hypoxic brain injury and 1(b) hanging. Short form conclusions of Suicide. 4 | CIRCUMSTANCES OF THE DEATH At around 21:09 on Monday 20th January 2020 Kesia Blaine Waller was discovered suspended from a ligature at her home address of JJ City Road, Winchester. She was taken to SGH where she was discovered to have a catastrophic hypoxic brain injury. Further treatment was deemed futile and life-sustaining treatment was withdrawn. Kesia sadly died in hospital on the 25th January 2020. 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. — At Kesia’s Inquest | heard that her place of residence, City Road in Winchester, was a residential housing unit for vulnerable young people aged 16-21. The facility meets a housing need only for the young persons placed there. It was found on the evidence that A2 Dominion employees did not have sufficient training or tools (i.e. implements) in place to prepare staff for the situation that they faced on the 20" January 2020 when they found Kesia hanging in her room, nor could they carry out any physical actions to assist her (i.e. cut her down). There appeared to be no prior appreciation of the risk(s) of self-harm, overdose or attempted suicide of residents, and so on discovering Kesia suspended in her room, the staff were inadequately prepared on multiple levels. (a) | heard that whilst there has been additional training for the staff on areas of risk such as self-harm, overdose and/or suicide, there have been no physical changes in terms of the provision of tools and implements that staff could use should they be confronted by a young person in distress and/or in need of life-saving attention. It appears to me that without multi-factorial changes there remains a real and significant risk that staff at the residential units will remain unable to take any immediate and potentially life- saving action. The only tools and equipment that remain supplied is a standard home- style first aid kit which is entirely ineffective if a young person has suspended themselves from a ligature. Although additional training and courses have been added to both the induction training and on-going professional development of staff within the residential units similar to City Road, | remain concerned by the way in which key policies and training are communicated and implemented as this does not appear to have changed. It was clear from the evidence that updates to policies are emailed to employees with a request that the employee responds to the email to confirm receipt. This proved to be wholly ineffective as what appeared to be expected by the company was that the employee would read, digest and understand the policy, and confirm when he/she had done so. The employee on duty on the 20th January 2020 was clearly unfamiliar with the appropriate policies and had only confirmed that he had received the email (which appeared to be all that was required) and not that he had actually read, digested and understood the appropriate policy/ies; how to apply them in practice and what was reasonably expected of him. Although enhanced risk training is now place, it appears to me that without any enhanced diligence to ensure that policies are actually read and understood by those working face-to-face with the vulnerable young adults then the overall effectiveness of risk training and identification is severely flawed. (b = 6 | ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you 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 26" 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. 8 | COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the following Interested Persons Kesia’s mother and to the LOCAL SAFEGUARDING BOARD (as the deceased was under 18). | have also sent it to Hampshire County Council and Ocean Safeguarding who may find it useful or of interest. | 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. | 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. 9 1% June 2021 Samantha Marsh oc
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.
33 Staple Gardens Winchester Hampshire SO23 8SR a2dominiongroup.co.uk Coroner’s Office FAO Ms Marsh The Castle Castle Hill Winchester SO23 8UL 14 July 2021 Dear Ms Marsh Regulation 28 Report to Prevent Future Deaths following the inquest of Kesia Waller who died on the 25/01/2020. I am writing to you in response to the concerns raised by your findings of the circumstance surrounding the tragic death of Kesia Waller. I will address the two concerns raised in turn. A: I heard that whilst there has been additional training for the staff on areas of risk such as self- harm, overdose and/or suicide, there have been no physical changes in terms of the provision of tools and implements that staff could use should they be confronted by a young person in distress and/or in need of life-saving attention. It appears to me that without multi-factorial changes there remains a real and significant risk that staff at the residential units will remain unable to take any immediate and potentially life-saving action. The only tools and equipment that remain supplied is a standard home-style first aid kit which is entirely ineffective if a young person has suspended themselves from a ligature. In response to the above, and as I mentioned in the inquest, we have already revamped the first aid training provided to include first aid action in relation to suicide, self-harm and overdose. As an organisation, we have also added preventative training around suicide awareness and conversations for all front-line staff. Additionally, we are providing ligature cutting kits in every office that provides any form of care and support provision and this will be fully rolled out by the end of July 2021. The kit includes a big fish safety knife which is recommended for ligature cutting. These kits will also have quick guides within them and are included in our audits for checking content. Finally, we have liaised with Hampshire County Council, which commissions our contract and numerous others around the county, on the outcome of the inquest and our response to this report. We have updated them on training and equipment provision so that they can share this practice with other providers who also provide housing related support. B: Although additional training and courses have been added to both the induction training and on- going professional development of staff within the residential units similar to City Road, I remain concerned by the way in which key policies and training are communicated and implemented as this does not appear to have changed. It was clear from the evidence that updates to policies are emailed to employees with a request that the employee responds to the email to confirm receipt. This proved to be wholly ineffective as what appeared to be expected by the company was that the employee would read, digest and understand the policy, and confirm when he/she had done so. The employee on duty on the 20th January 2020 was clearly unfamiliar with the appropriate policies and had only confirmed he had received the email (which appeared to be all that was required) and not that he had actually read, digested and understood the appropriate policy/ies; how to apply them in practice and what was reasonably expected of him. Although enhanced risk training is now in place, it appears to me that without any enhanced diligence to ensure that policies are actually read and understood by those working face-to face with the vulnerable young adults then the overall effectiveness of risk training and identification is severely flawed. I want to reassure you that we take our responsibilities over policies and procedures very seriously. All staff are formally inducted over a period of four months. During this they are required to read all relevant policies and procedures relating to their role. As an organisation, we carry out regular reviews during the probation and formal ones are recorded at 2 weeks, 2 months and 4 months. Staff also undertake ‘on the job’ face to face and online training and ‘buddying’ to ensure new starters understand the requirements of the role and the policies/procedures that they should follow. As an organisation we update and amend our procedures at least every three years, if not sooner, if there is a change in best practice or legislation. We have a dedicated team who oversee this. We involve staff in policy and procedure reviews to ensure that they work effectively on the ground. We also take on board operational feedback and ensure that this is reflected within changes. All staff receive a ‘purple ribbon’ email that highlights changes to any policy and procedure. As a result of the inquest, we have supplemented the above to include an interim solution whereby once a ‘purple ribbon’ email is sent that the staff member has to confirm they have read and understood the changes. This is then recorded and held centrally. Policies and Procedures have also been added to the agenda of all team meetings. Any changes and amendments are discussed at team meetings to check understanding and how these will be applied in practice, this is also minuted and audited. As an organisation, we are also upgrading our HR software systems, which includes improved digital records of training undertaken and policies and procedures read. This will enhance the ‘purple ribbon’ process set out above by automating it. This is due to be implemented by 2022/23. I hope that the information I have given provides suitable assurance that the findings of your investigations and the areas you have highlighted for the prevention of future deaths have prompted action and been the focus of continual improvement and our commitment to support the safety and well-being of those that we support. Yours sincerely Director of Supported Housing
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