Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2021-0306, written 14 Sep 2021. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 14 Sep 2021 |
|---|---|
| Reference | 2021-0306 |
| Deceased | Siwan Smith |
| Coroner | Caroline Saunders |
| Coroner area | Gwent |
| Category | Community health care · Mental Health related deaths · Suicide (from 2015) · Wales prevention of future deaths reports (2019 onwards) |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 REGULATION 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Practice Manager at The Medical Centre, Cardiff Road, Taff's Well, CF15 7YG 1 CORONER 2 3 I am Caroline Saunders, Senior Coroner for the Area of Gwent CORONER'S LEGAL POWERS 1 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 4/12/2020 an investigation was opened into the death of Siwan Llio SMITH The investigation concluded at the end of the inquest on: 9/9/2021 The conclusion of the inquest was recorded as: Suicide The medical cause of death was: 1a) Suspension by ligature 4 CIRCUMSTANCES OF THE DEATH Siwan Smith had a long-standing history of anxiety and depression which was exacerbated during the Covid 19 pandemic. Siwan's mental health deteriorated and she started to have suicidal thoughts. Siwan did not have ongoing support from either primary or secondary mental health services. On 23rd November 2020 Siwan became overwhelmed by her anxieties and took her own life by hanging at her home address. 5 CORONER'S CONCERNS During the course of the inquest, 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. Response to Mental Health Concerns by Reception Staff During the course of the inquest, Mr Martin Smith, Siwan's husband, raised concerns that on 18th November 2020, Siwan telephoned the Medical Centre to obtain an urgent appointment with a doctor. She was informed by the receptionist that the earliest appointment was on 30th November 2020. The Medical Centre provided me with a report which indicated that when Siwan asked about whether there were any emergency appointments for mental health problems she was advised that these are not routinely offered unless a patient is having "bad thoughts". Your report states that an emergency appointment was not requested and at no point was it suggested the call was a mental health emergency. The Medical Centre provided me with a recording of the telephone exchange between Siwan and the receptionist. I found during the inquest that Siwan asked repeatedly if she could have an earlier appointment and was clearly upset that she could not. She was not asked if she was having bad thoughts or whether she required urgent mental health support. It was clear towards the end of the conversation that Siwan was distressed. I also received in evidence a letter dated 8 March 2021 written By , the Practice Manager to Mr Smith, in which she implies that the receptionists are not clinically trained to make assessments. I accept this, however in the circumstances I determined that Siwan should have received a call back from someone who was clinically trained to ascertain whether she required an urgent mental health assessment. In the circumstances I did not find that a different course of action would have prevented Siwan's death or would have altered the outcome. However I am concerned that lives could be put at risk in the future if there continues to be a lack of awareness of when a patient may require a clinical assessment in relation to their mental health. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. I should be grateful if the following information be provided to me: 1. Confirm whether any steps have or will be taken to escalate calls to clinical staff in the circumstances described. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely 04/11/2021, I, the Coroner, may extend this 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 necessary. 8 COPIES AND PUBLICATION I have sent a copy of my report to the Chief Coroner and the following Interested Person (s) • 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 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 14/9/21 Signed Ca .line Saunders He Majesty's Senior Coroner for the Area of Gwent.
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.
JA Cardiff Road Taff's Well CF'15 7YG Castle View Dr Dr Dr Dr 4th November 2021 Dear Ms Saunders Thank you for your Regulation 28 report following the inquest touching upon the death of Mrs Siwan Smith. We acknowledge the points raised and have reflected on the event. We have implemented the following strategies: • We appreciate that time is pressured on reception and call handling. In order to quickly alert administrative staff of mental health risk, we have undertaken an exercise whereby all patients on mental health medication and / or a documented history of mental illness have a pop up message stating "High risk mental health". This is displayed as soon as a patient's record is activated, including reception and call handling stages. o Status = Complete • As noted by in her statement, the call handling and reception staff are not trained in mental health risk assessment. We have therefore implemented a strategy whereby patients contacting the practice with mental health concerns are offered the next available appointment. Where the patient feels that an earlier appointment is required, they will be immediately added to the "on the day triage list" for urgent response by the on-call GP. o Status = Complete • The e-consult platform provides an excellent risk assessment of depression and provides a PHQ-9 depression score. This provides a convenient and safe method of accessing help from the practice. It enables patients who may struggle to get their concerns across verbally, especially when discussing sensitive points, to articulate these in a structured manner with prompts. We hope that providing this service will help our younger, working age population such as Mrs Smith to alert us of their mental health issues promptly at their convenience. E-consults are continuously monitored throughout the day and those flagged as high risk based on PHQ-9 score (which includes a question on suicidal thoughts) are passed to the on-call clinician for immediate call-back. The E-consult option is provided for patient convenience, in addition to the existing method of booking via telephone and is not a replacement. o Status = Complete Mrs Smith's death is tragic, and indeed one that has affected us all at the practice. We have undergone a period of reflection and have had frequent discussions surrounding the incident and ways of preventing similar events in the future. As an immediate response we feel that the above strategies, although simple, have improved acute staff awareness of patient's mental health status and improved access. We have many other thoughts to improve general awareness to both staff and the public which we will continue to explore and develop. These are our immediate strategies which have been implemented. Yours sincerely Dr GP Partner at Taff's Well Medical Centre & Castle View Surgery Branch: Castle View Surgery, Castle View Shopping Centre, Caerphilly CF83 1 SN
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