Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2021-0396, written 25 Nov 2021. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 25 Nov 2021 |
|---|---|
| Reference | 2021-0396 |
| Deceased | Malcolm Dixon |
| Coroner | Chris Morris |
| Coroner area | Manchester South |
| Category | Mental Health related deaths · Hospital Death (Clinical Procedures and medical management) 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. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Rt. Hon. Sajid Javid, Secretary of State for Health and Social Care. | CORONER | am Chris Morris, Area Coroner for Greater Manchester (South). 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. http:/Awww.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 htto://www.legislation.gov.uk/uksi/2013/1629/part/7/made | INVESTIGATION and INQUEST On 11th March 2020, Alison Mutch OBE, Senior Coroner for Greater Manchester (South), opened an inquest into the death of Dr Malcolm | Dixon who died on 29th December 2019 at the Priory Hospital, | Altrincham. The investigation concluded at the end of the inquest which I | heard between 1st and 5th November 2021. | The consultant pathologist who undertook the post mortem examination | determined Dr Dixon died as a consequence of: At the end of the inquest, | recorded a narrative conclusion that Dr Dixon took his own life whilst his state of mind was adversely affected by a severe depressive illness. CIRCUMSTANCES OF THE DEATH During autumn of 2019, Dr Dixon became unwell with what was later diagnosed as a severe depressive illness. Dr Dixon was admitted to the Priory Hospital, Altrincham as an informal, voluntary patient and was treated by means of medication, observation by and interaction with staff, and participation in activities sessions. Dr Dixon died on 29th December 2019 at the hospital, as a consequence 0° te This was an impulsive act undertaken within the context of an episode of severe mental illness. CORONER'S CONCERNS The MATTERS OF CONCERN are as follows. — 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 MATTER OF CONCERN is as follows. — The Court heard it was likely that an observation chart, designed to record regular observations, had been pre-populated by a staff member to show when observations were intended to be taken as opposed to recording when they actually took place. Additionally, the Court heard that the automatic timings generated by the electronic care record system in use at the Priory could be over-written manually, thus leading to inaccurate times being recorded in the records. The following concerns arise from the above: 1. Given the particular importance of documented observations being taken at specific intervals on mental health wards, it is a matter of concern that standardised observation charts (together with accompanying standard rules as to how they should be completed) are not in use across these settings both in the NHS and private sectors; 2. For similar reasons, it is a matter of concern that automatic time- stamps generated by electronic care records systems can be overwritten by users without the corresponding record showing clearly that this has happened, whilst also recording of the actual time an entry has been made. 3. It is a matter of concern that, where record keeping on a ward is undertaken by unregistered staff such as Nursing Assistants and Healthcare Assistants, such individuals are not subject to professional requirements in respect of documentation, such as those which exist for doctors and nurses. 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 20th January 2022. |, 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 Broudie Jackson Canter solicitors on behalf of Dr Dixon's family. | have also sent a copy to Browne Jacobson LLP on behalf of the Priory Group Ltd., and the Care Quality Commission, who may find it useful or of interest. | 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. oa Dated: 25th November 2021. Signature: Chris Morris HM Area Coroner, Manchester So
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.
Our Ref: PFD - 1379232 Chris Morris Area Coroner Coroner Service Team 1 Mount Tabor Street Stockport SK1 3AG Dear Mr Morris, 1 September 2022 Thank you for your letter of 25 November 2021 to the then Secretary of State for Health and Social Care, Sajid Javid, about the death of Dr Malcolm Dixon. I am replying as Minister with responsibility for Primary Care and Patient Safety, and thank you for the additional time allowed. Firstly, I would like to say how saddened I was to read of the circumstances of Dr Dixon’s death and I offer my sincere condolences to his family and loved ones. The circumstances your report describes are very concerning and I am grateful to you for bringing these matters to my attention. In preparing this response, Departmental officials have made enquiries with NHS England, NHS Digital and the Care Quality Commission (CQC). You may wish to know that CQC has a key responsibility in the overall assurance of safety and quality of health and adult social care services. Under the Health and Social Care Act 20081 all providers of regulated activities, including NHS and independent providers, must register with CQC and follow a set of fundamental standards of safety and quality below which care should never fall. All providers of CQC-regulated activity have a duty to ensure that their staff have the skills, knowledge and experience for the work undertaken. Health Care Assistants (HCAs) and Assistant Practitioners (APs) have a duty of care and a legal responsibility to the patients they see and care for. HCAs are not registered with a professional body, However, they are accountable to their employer to follow their contract of employment. Accordingly, employers have a responsibility to train, supervise and have oversight of their HCAs. It is vital that employers make sure employees only work within the limits of their competence. Employers also accept vicarious liability for their employees and are accountable for the actions and omissions of the employee. If a registered nurse is responsible for delegating tasks to an HCA or AP, the registered nurse is responsible under the Nursing and Midwifery Council (NMC) Code of Conduct2 for the safe delegation of that task. The NMC code states that registered nurses must: • • • only delegate tasks and duties that are within the other person's competence; make sure that everyone they delegate tasks to is adequately supervised and supported; and confirm that the outcome of any task they have delegated to someone else meets the required standard. I have been made aware that since its registration with the CQC, Priory Hospital Altrincham has been inspected five times and all wards have received routine visits from Mental Health 1 https://www.legislation.gov.uk/ukpga/2008/14/contents 2 https://www.nmc.org.uk/globalassets/sitedocuments/nmc-publications/nmc-code.pdf Act Reviewers. The hospital has a permanent registered manager who has been in post for four years. Regular engagement meetings take place with the registered manager, with the most recent meeting taking place in November 2021. I have been informed that at this meeting, CQC had noted positive plans. Furthermore, Priory Hospital Group had changed ownership in 2021, and is currently owned by a large European healthcare provider. They have committed to invest in the hospital sites, including replacing the current computerised record keeping system. More generally, NHS Digital’s jurisdiction is limited to operating nationally specified requirements, with deployment of systems that meet such requirements supported by national assurance. This may take the form of independent assurance or through a framework of self- declaration against mandated requirements. NHS Digital does, for example, operate the Digital Care Services catalogue supporting eligible users to buy assured digital tools and systems through approved frameworks. However, the use of these is not mandatory and providers remain responsible for: i) assessing whether the functionality is fit for their purposes; ii) training and ensuring staff use such systems as intended; and iii) ensuring the clinical safety of their patients. NHS Digital’s remit does not include the specification of IT systems used within Mental Health Settings. However, from a clinical perspective it is agreed that electronic patient record systems should allow users to edit automatically-generated time stamps to accurately reflect when an observation actually took place as often it will not be contemporaneous, and that an associated audit trail should show the time the record entry was made and subsequent changes to it. Pursuant to section 250 of the Health and Social Care Act 20123, NHS Digital publishes information standards, including DCB0129: Clinical Risk Management: its Application in the Manufacture of Health IT System4 and DCB0160: Clinical Risk Management: its Application in the Deployment and Use of Health IT Systems5, which establish a clinical risk management framework to support the safe development and use of health IT systems for health and adult social care purposes in England. These should be complied with by both the supplier of the system (DCB0129) in question and the care provider (the Priory) using it (DCB0160). Organisations must consider how failure or misuse of the systems could impact the management or delivery of care to the patient/service-user, estimate the risk and where necessary control it to an acceptable/accepted level. Evidence of this work having been done must be recorded in a Clinical Safety Case Report. I hope this response is helpful, and I thank you for bringing these issues to my attention. Yours sincerely, JAMES MORRIS MP Minister for Patient Safety and Primary Care 3https://www.legislation.gov.uk/ukpga/2012/7/section/250#:~:text=250Powers%20to%20publish%20in formation%20standards&text=(1)The%20Secretary%20of%20State,and%20publish%20an%20inform ation%20standard. 4 https://digital.nhs.uk/data-and-information/information-standards/information-standards-and-data- collections-including-extractions/publications-and-notifications/standards-and-collections/dcb0129- clinical-risk-management-its-application-in-the-manufacture-of-health-it-systems 5 https://digital.nhs.uk/data-and-information/information-standards/information-standards-and-data- collections-including-extractions/publications-and-notifications/standards-and-collections/dcb0160- clinical-risk-management-its-application-in-the-deployment-and-use-of-health-it-systems
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