Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2021-0200, written 9 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 | 9 Jun 2021 |
|---|---|
| Reference | 2021-0200 |
| Deceased | Denton Duhaney |
| Coroner | Mary Burke |
| Coroner area | West Yorkshire Western Division |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths · Mental Health related deaths · Suicide (from 2015) |
| Organisation named | South West Yorkshire Partnership Teaching NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
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IN THE WEST YORKSHIRE (WESTERN) CORONER’S COURT IN THE MATTER OF: The Inquest Touching the Death of Denton Donovan DUHANEY A Regulation Report — Action to Prevent Future Deaths REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: 1. The Chief Executive of the Mid Yorkshire Hospitals NHS Trust 2. The Chief Executive South West Yorkshire Partnership NHS Foundation Trust 1 CORONER | am Mary Burke Assistant Coroner for the area of West Yorkshire Western Division. 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 Inquest opened 12! July 2019 into the death of Denton Donovan Duhaney Inquest concluded 30 March 2021 | recorded the medical cause of Mr Duhaney’s death was due to Hanging (Asphyxia) and a conclusion of suicide 4 CIRCUMSTANCES OF THE DEATH On the 22"4 June 2019, Mr Duhaney had been admitted to the Accident and Emergency Department of Dewsbury District Hospital with both physical and mental health concerns. He was assessed by a nurse from the Psychiatric team, who recommended he should be admitted as an informal patient on to a psychiatric ward. However, no bed was available and he was therefore transferred to Pinderfield’s Hospital early on the morning of the 23" June 2019 and admitted on to the Acute Medical Assessment Unit. Mr Duhaney underwent a further mental health assessment at 17.00hrs by a member of the Wakefield Home Based Treatment team following a request by the Kirklees Home Based Treatment team within whose area Mr Duhaney resided. At this point a psychiatric hospital bed could still not be found within the area (Mr Duhaney had requested to remain in the area as his partner was gravely ill). At the time of this assessment an alternative treatment plan was agreed with Mr Duhaney namely that when he was physically well enough to be discharged, he would be provided with care and support in the community setting by the Kirklees Home Based Treatment Team. At the time of this assessment Mr Duhaney was assessed as being at high risk of further mental health deterioration. Following assessment the Wakefield Home based Treatment team referred Mr Duhaney back to the team in Kirklees. It appears that at no time either at the time of transfer or during his admission was Mr Duhaney referred to the psychiatric services within Pinderfield’s Hospital. In the ensuing days the Kirklees Home Based Treatment team made telephone contact with both Mr Duhaney and Acute Medical Assessment unit, leaving contact telephone details and a request that they be contacted and notified when Mr Duhaney was to be discharged. It appears Doctors on the ward believed Mr Duhaney was awaiting a hospital Psychiatric assessment. On the afternoon of 25" June 2019 Mr Duhaney approached a member of the nursing team at the nurses station and stated he wished to self-discharge. Blood test results were still awaited. The nurse gave evidence at the inquest, she stated that she spoke to a female doctor the identity of whom she could not recall advising her of Mr Duhaney’s wishes, the doctor did not undertake an assessment upon Mr Duhaney, the nurse proceeded to warn Mr Duhaney that his discharge was against Medical advice and got him to sign the appropriate form. The nurse in evidence stated she was unfamiliar with the trusts protocol document “Standard Operating Procedure for Managing the Discharge of Patients. Mr Duhaney left the hospital. No hospital staff member contacted Kirklees Home Based Treatment Team of Mr Duhaney’s self discharge. The lead investigator of a Serious Incident Investigation Report undertaken by South West Yorkshire Partnership Trust in respect of the involvement of Home Based Treatment Teams stated in evidence that he was advised by the Modern Matron at Pinderfield's Hospital that it was normal Practice of the hospital not to arrange follow up in the community in these circumstances when it was planned for if, the patient self discharges. Five days later on 30" June 2019 a staff member from Kirklees Home Based Treatment team contacted Pinderfield’s Psychiatric Liaison Team seeking an update upon Mr Duhaney, only to be advised that Mr Duhaney had self discharged 5 days previously. Immediate steps were taken by Kirkiees Home Based Treatment to try and make contact with Mr Duhaney to no gain. As a result the police were contacted who attended at his home, now the early hours of 1% July 2019, they forced entry and found Mr Duhaney with a length of medical plastic piping around his neck which had been secured to an adjoining door handle, his death was confirmed a short time later by an attendant paramedic. Mr Duhaney appeared to have been dead for some time, he was still wearing hospital clothing beneath his own clothing. 5 CORONER’S CONCERNS The MATTERS OF CONCERNS are as follows: 1. Mr Duhaney was a patient at Pinderfield’s Hospital between 239 and 25" June but at no time was he assessed or receive treatment by the in house psychiatric team despite the fact that he had an underlying psychiatric presentation. 2. Pinderfields hospitals discharge protocol does not appear to have been adhered to when Mr Duhaney expressed a wish to self-discharge. 3. No one from Pinderfield’s Hospital contacted Kirklees Intensive Home Based Treatment Team to notify them of Mr Duhaney’s self discharge. 4. Kirklees Home Based Treatment Team last had contact with Pinderfield’s Hospital on 24" June 2019. It was 6 days later that they made a further call to the hospital seeking an update upon Mr Duhaney. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | 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 3 August 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 | have sent a copy of my report to the Chief Coroner and to the following Interested Persons:- | 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. ®@ Klaleter tor MT. Boks Dated: 9° June 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.
Ms M Burke Assistant Coroner Trafalgar House Police Station Nelson Street Bradford BD5 0DZ 18.8.2021 Dear Ma’am Deputy Chief Executive Director of Operations Trust Headquarters – Block 7 Fieldhead Hospital Ouchthorpe Lane Wakefield WF1 3SP Regulation 28 Report Response – Denton Duhaney – 25th March 2021 and 30th March 2021 In response to the Regulation 28 report the Trust received on 21st July 2021, we wish to respond with the following information. As you will recall, you heard evidence regarding Regulation 28 matters in both written and oral evidence from Mr , General Manager for Gatekeeping and Liaison Services. provided two statements to assist with the proceedings; these were dated 23rd Mr and 29th March 2021. This response builds upon the evidence provided by Mr as part of the inquest proceedings. 1. Mr Duhaney was a patient at Pinderfield’s Hospital between 23rd and 25th June but at no time was he assessed or received treatment by the in house psychiatric team despite the fact that he had an underlying psychiatric presentation The statement of Mr dated 23rd March 2021, paragraphs 3.1 and 3.2, stated: I can confirm that any patients assessed by a Psychiatric Liaison Team in a hospital setting remain on the team’s caseload until the patient leaves the hospital site. Therefore, if the patients risk change prior to them leaving the hospital the team will be able to provide a review of the patient and offer support as needed. The Standard Operational Policy [Wakefield/Dewsbury and the Calderdale/Kirklees Psychiatric Liaison Team] has been reviewed and amended to ensure consistency of practice across the Trust’s Psychiatric Liaison Teams (e.g. there is no difference in the processes of the Wakefield/Dewsbury PLT, and the Calderdale/HRI PLT as a result). teams two for At the time of the incident the Psychiatric Liaison Teams came under different management structures, however, in January 2020 this structure was amended, and these teams are now within the same Business Delivery Unit. It is envisaged that the change in structure will support the function of the services by ensuring a uniform management approach. In addition to the above information and changes, I can confirm that arrangements are made for there to be a handover of care between Psychiatric Liaison Teams where it is known an individual is being transferred between Acute hospitals in the Trust’s area of operation. The principle that the Psychiatric Liaison Teams maintain a patient on their caseload is an additional safeguard that was not present within Pinderfield’s and Dewsbury District Hospital due to the statement of 23rd differing Standard Operational Procedures referred to in Mr March 2021. 2. Pinderfields hospitals discharge protocol does not appear to have been adhered to when Mr Duhaney expressed a wish to self-discharge. The above relates to the discharge protocol implemented by Mid Yorkshire Hospitals NHS Trust. We do not propose responding to this concern. 3. No one from Pinderfield’s Hospital contacted Kirklees Intensive Home Based Treatment Team to notify them of Mr Duhaney’s self discharge. 4. Kirklees Home Based Treatment Team last had contact with Pinderfield’s Hospital on 24th June 2019. It was 6 days later that they made a further call to the hospital seeking an update upon Mr Duhaney. Points 3 and 4 above have elements that overlap, and we have therefore responded to both below. It is understood that Mid Yorkshire Hospital NHS Trust will also provide their own response to point 3 as this can be interpreted to apply to both Trusts. The statement of Mr dated 29th March 2021, paragraphs 3 through 6, stated: During the course of the inquest proceedings on 25th March 2021, evidence was heard that the Kirklees Intensive Home Based Treatment Team (IHBTT) did not have guidance on how and when to maintain contact with a service user whilst they were awaiting discharge from an acute hospital. It has historically been the case that an Acute Hospital would ensure that follow up arrangements are made, and the agreements are met at the point of discharge (i.e. to contact the relevant services on discharge). However, on hearing the evidence of witnesses it was evident an additional safety netting approach would be required and during the course of my own evidence, I suggested that this was an area that required immediate action. This statement has been prepared to provide an update to HM Assistant Coroner, Ms Burke, on this particular point. I will today be producing and disseminating guidance to staff within the Trust community just the Intensive Home Based Treatment Team) to provide clear services (not instructions around maintaining contact with a service user awaiting discharge from an acute hospital, but equally to maintain contact with the Psychiatric Liaison Team and/or Acute Ward to ensure a seamless transition of care into the community. The above is intended to be an interim measure and going forward a more detailed review of this issue will be undertaken. and the relevant team Following further consideration of the interim guidance by Mr managers, the guidance disseminated on 29th March 2021 is a sufficient safety net to ensure a seamless transition of care from an Acute Hospital to Community Mental Health Services. Assurances have been provided by the relevant Services Managers that contact is being maintained with service users awaiting discharge from Acute Care Team and the Psychiatric Liaison Team (if involved in the service users care). As part of our ongoing partnership working with Mid Yorkshire Hospitals although we are responding to your concerns individually, we have had sight of each other’s response. I do hope the above information is of assistance and answers the concerns raised within your Regulation 28 report following the sad death of Denton Duhaney. We would like to offer our sincere condolences to Mr Duhaney’s family and friends. Yours faithfully, Deputy CEO South West Yorkshire Partnership NHS Foundation Trust
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