Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2021-0257, written 15 Jul 2021. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 15 Jul 2021 |
|---|---|
| Reference | 2021-0257 |
| Deceased | Henry Holcombe |
| Coroner | Veronica Hamilton-Deeley |
| Coroner area | Brighton & Hove |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
VERONICA HAMIL TON-DEELEY DL, LL.B. Her Majesty's Senior Coroner for the City of Brighton & Hove THE CORONER'S OFFICE WOODY ALE, LEWES ROAD BRIGHTON BN23QB 1 2 3 4 5 CORONERS SOCIETY OF ENGLAND AND WALES ANNEX A REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) NO TE: This form is to be used after an inquest. THIS REPORT IS BEING SENT TO: 1. 2. , CEO of Sussex Partnership Foundation NHS Trust , Deputy Chief Nurse CORONER I am Veronica HAMILTON-DEELEY, Senior Coroner, for the City of Brighton and Hove. 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. INVESTIGATION and INQUEST On 11 th March 2021 I commenced an investigation into the death of Henry James Holcombe. The investigation concluded at the end of the inquest on12th July 2021.The conclusion of the inquest was natural causes. CIRCUMSTANCES OF THE DEATH See Record of Inquest 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) The ongoing failure of SPFT to require their staff to comply with the Trusts therapeutic engagement and observation policy. Especially those sections which relate to night times or when patients are believed to be sleeping (see para 4.5.5, 4.5.7 and table 1 -page 5). Since 27.12.2019 to 5.3.2021 there have 1 VERONICA HAMILTON-DEELEY DL, LL.B. Her Majesty's Senior Coroner for the City of Brighton & Hove THE CORONER'S OFFICE WOODYALE, LEWES ROAD BRIGHTON BN23QB 6 7 been three occasions when patients described as asleep over a series of observations, have actually been found to have been dead for several hours. Serious Incident reports have promised action but nothing effective has been produced. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you AND your organisation 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 04th October 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 1. 2. 3. Secretary of State for Health, Department of Health 4. Chief Executive, NHS England , USH NHS Trust I have also sent it to:- 1. 2. Head of patients safety Sussex and B&H clinical commissioning group Inspector of the CQC Who may find it useful or of interest. 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 Date: 15th July 2021 2
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 Penelope Schofield
HM Senior Coroner
Acting Senior Coroner for Brighton &
Hove
Coroner's Office
Woodvale
Lewes Road
Brighton
BN2 3QB
Office of the Chief Executive
Trust Headquarters
Swandean
Arundel Road
Worthing
West Sussex
BN13 3EP
4 October 2021
Dear Ms Schofield
We write in response to Ms Hamilton-Deeley's Regulation 28 Report, dated 15 July
2021, following the Inquest into the death of Mr Henry Holcombe.
We were saddened by Mr Holcombe's death and have extended our sincere
condolences to his family.
We fully agree with Ms Hamilton-Deeley's concerns regarding the need to ensure that
observations are appropriately completed, in accordance with the Trust's Therapeutic
Engagement and Observation Policy (the 'Policy'), especially at night. We are
strengthening our clinical practices in the light of Mr Holcombe's death and the
broader learning from Serious Incidents where full adherence to our Policy has been
identified as a factor.
The Trust's actions, to date, in relation to this issue, have focused on staff training,
competency and understanding of our Policy. This stipulates that: ‘If a member of staff
is not able to observe the patient move or breath they must ensure the patient is
conscious which will require entering the bedroom’ and staff competency and
understanding of the Policy is assessed through competency checks. However, it is
clear that further, sustained action is required to ensure that this requirement is fully
understood and adhered to by all clinical staff.
Specifically, in response to the findings of our investigation into Mr Holcombe's death,
the
we have strengthened our
internal monitoring arrangements
to ensure
requirements of the Policy are effectively embedded in clinical practice. Additionally,
the training provision has been enhanced - including assessment of agency and bank
staff - and Policy compliance is now reviewed on a weekly basis by the Ward Manager
and on a monthly basis by the Matron.
Also, although Ms Hamilton-Deeley's concerns related particularly to safety at night,
we have recognised that a systemic quality improvement approach is needed to
ensure that therapeutic observations are of an appropriate standard. As a result, we
are undertaking a robust programme of therapeutic observation Quality Improvement
('QI') work. The aim of this work is to improve the quality of therapeutic observations
in terms of safety, effectiveness and experience; specifically, to ensure observations
are a therapeutic, individualised and skilled intervention that is responsive to a
patient's needs, are least restrictive, and aimed at recovery. This QI work will give
specific attention to:
• the competencies of individuals' undertaking therapeutic observations;
• the need for an individualised approach to care;
• proactive exploration of the patient experience and a focused review of night-
time observations, including seclusion and physical observations.
Additionally, consideration is being given to the potential use of technological aids to
support patient safety and enhanced physical observation, which includes an
electronic system to remotely monitor a patient’s respiration, movement and heart rate
and flags immediate changes to the patient’s physical presentation.
The QI work will be completed by 31st December 2021. We anticipate that you would
want to be updated on the results, so we will write with an update by 1 February 2022.
In the meantime, if further information of clarification would be of assistance to you,
please do not hesitate to contact either one of us.
Your sincerely
Chief Executive
Dr
Chief Nursing Officer
See every Prevention of Future Deaths report matching Hospital Death (Clinical Procedures and medical management) related deaths, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.